Standing Committee A

[Miss Ann Widdecombe in the Chair]

NHS Reform & Health Care Professions

Clause 12 - Further functions of the Commission for Health Improvement

Question proposed [this day], That the clause stand part of the Bill. 
 Question again proposed.

Oliver Heald: I welcome you to the Chair, Miss. Widdecombe.
 I asked the Minister two further questions about the clause. The first question related to the vexed issue of the effect of clause 12(5) on the role of the Audit Commission. Under section 21 of the Health Act 1999, the Commission for Health Improvement can undertake Audit Commission work or work jointly with the Audit Commission. Subsection (5) requires the Audit Commission to consult the commission about its value-for-money studies. The notes refer to that as ''better co-ordination''. Will the Audit Commission continue in practice to undertake its value-for-money studies when the CHI is, or could be, competent under section 21 of the 1999 Act? If the Minister is prepared to give a clear statement on that, we will be happy; or relatively so. 
 Secondly, clause 12(2)(c) adds a provision for the CHI to report on 
''the quality of data obtained by others relating to the management, provision or quality of, or access to or availability of, health care for which NHS bodies or service providers have responsibility''. 
Does that provide a route by which the problems encountered by bodies such as the national confidential enquiry into perioperative deaths might have their concerns addressed, or is it simply designed to discover why the information that the Health Department receives is less accurate than it might be? 
 I will give a taste of the problems that the cancer study revealed. The NCEPOD study referred to the problem of data and explained that it found 
''poor hospital information systems. Medical records and their content are one of the building blocks of our medical system and problems with the organisation and content of medical records have a considerable impact on clinical care and education. The report contains evidence that medical record keeping is falling below acceptable standards. Unfortunately, poor record keeping will inevitably lead to poor completion of NCEPOD questionnaires, which might call into question the validity of some of the data in the Enquiry.'' 
The report has become a huge media story, and it is obviously not helpful to the Government to be told that cancer is dealt with in such an appalling way in this country. If a problem exists with the methodology, 
 data and medical records, it would be good to sort it out so that we know where we are. The study draws conclusions such as: 
 ''Most patients with cancer who die within 30 days of an operation are admitted as an emergency or urgently and many are not referred either to a surgeon with a subspecialised oncology interest, a multidisciplinary team, medical oncologist or specialist cancer nurse when it is indicated. Clinical networks and local guidelines should be constructed in order to ensure that all patients with cancer receive and early and appropriate referral to specialists.'' 
There is obviously a serious concern about the treatment of cancer. 
 Will the provision in subsection (2)(c) help reports such as the NCEPOD one, or is it designed for internal Department of Health purposes?

John Hutton: I, too, welcome you back to the Committee, Miss Widdecombe. You have missed many interesting debates, but I hope that we will entertain you this afternoon.
 The hon. Gentleman claims to ask two further questions, although only one of them is a genuine further question, as his remarks about subsection (5) have been exhaustively debated. He described it as a vexed question, but there is nothing vexed about the intent or purpose behind that subsection. To put the hon. Gentleman and his hon. Friends at ease, the Bill makes no changes to the value-for-money responsibilities of the Audit Commission.

Oliver Heald: I asked whether the Audit Commission would continue in practice to undertake its value-for-money studies when the CHI is, or could be, competent under section 21 of the 1999 Act.

John Hutton: That is precisely the point that I have just made, so I hope that we can move on. I have spent the best part of 45 minutes answering that question in a variety of ways, and I hope that we have now put the issue to bed.
 The hon. Gentleman asked about confidential inquiries. In the main, the CHI's role will be to follow up specific issues relating to service provision that can be traced to individual providers, when it can make sensible recommendations. As the hon. Gentleman probably knows, the information from confidential inquiries is anonymised. Such inquiries do not state, ''This hospital is doing X and that hospital is doing Y, and it is all terrible.'' It is anonymised information, so the issues raised by those inquiries are different from issues relating to individual service performance in individual trusts, hospitals or units. 
 The responsibility for oversight of confidential inquiries lies with the National Institute for Clinical Excellence, which makes sense, given that organisation's other responsibilities. There is no prospect of confidential inquiries coming within the remit of the clause, because CHI's purpose and function is different. 
 The issues that the hon. Gentleman raised relating to the confidential enquiry report on cancer services will be addressed differently, in ways that will involve the Commission for Health Improvement. For 
 example, the Government have published their cancer plan, which earmarks investment for improved cancer services. The NHS plan addresses the issue of cancer services and the importance of speed of access to specialist care in the event of suspected cancer. The Commission for Health Improvement will have an expanded role in relation to the performance of the NHS, the cancer plan and meeting the plan's objectives. It will be able to pursue the issues of quality care provided to patients who have cancer with a similar jurisdiction or remit in relation to other hospital-based service provision. The CHI will have an obvious role to play in the areas to which he referred, but is unlikely to develop responsibilities as regards confidential inquiries.

Oliver Heald: Clearly, subsection (2)(c) exists because the Government are unhappy with the quality of information that they are receiving from some NHS bodies and providers. They are sending in the CHI to review and report on that and to ensure that information is as accurate as possible. The National Institute for Clinical Excellence has a supervisory role for the study to which I referred, but, if that body is frustrated because the quality of information that it receives for its studies is no good, will it be able to send in the CHI, or does it have its own arrangements for improvement of quality?

John Hutton: Certainly, the CHI has an important responsibility in relation to quality of data that the NHS uses, and the confidential inquiry reports produce important messages about the quality of service. However, that information is anonymised and, although I do not dispute that the CHI may want to consider the data that is assembled, and will be able to do so if it so chooses, we do not have any intention to transfer responsibility for the confidential inquiries from NICE to the CHI.

Evan Harris: I am interested in this information. I remember how useful NCEPOD, the national confidential enquiry into perioperative deaths, CESDI, the confidential enquiry into stillbirths and deaths in infancy, and other inquiries were when I was working in the health service. They are powerful tools. Because they are confidential, they have a ''Heineken effect'', whereby they can reach parts of the health service and data that other inquiries cannot reach. I listened carefully to the Minister's remarks, but surely it would be sensible to concentrate and co-ordinate all such inquiries, whether confidential or not, within one body. NICE seems to be set up for a rather different purpose from CHI and these confidential inquiries.

John Hutton: I apologise if I have not made my point clearly. That type of data collection is fundamentally different from most other types, which are not anonymous. That is why there is a difference and why we have drawn the line in a different place. NICE has the overall responsibility for this issue in the NHS and that is an appropriate place for the confidential
 inquiries to lie. CHI's responsibilities are slightly different. It has a remit to improve data quality and it may want to consider that in relation to the confidential inquiries. However, the responsibility for overseeing them lies in the right place.

Evan Harris: I remember debates in which the Minister lamented the fact that there was no amendable primary legislation governing NICE or its remit. I hope that the Government will reconsider the issue. It would be useful to have the same type of debates and scrutiny over the role, limits, powers and independence of NICE that we are having about the remit and role of the Commission for Health Improvement regarding audits of quality.

John Hutton: I am not trying to prevent the hon. Gentleman from having that debate if he so chooses, but we look in vain for any sign that he wishes to have that debate in relation to the Bill; he has not tabled any amendments to that effect. He is free to table whatever amendments he likes on these issues; then we may have the debate that he is seeking. We are clear in our mind about where responsibility should lie. I have explained to the hon. Gentleman some of the thinking behind that and why we are not proposing any amendments along those lines. However, the hon. Gentleman is perfectly free to do so at any time.
 This has been a long debate. I have tried several times to respond to the points raised. I have nothing further to add and I hope that the Committee will support the inclusion of the clause. 
 Question put and agreed to. 
 Clause 12 ordered to stand part of the Bill.

Clause 13 - Commission for health improvement: inspections and investigations

John Hutton: I beg to move amendment No. 124, in page 17, line 42, after 'providers' insert
', and persons who provide or are to provide health care for which NHS bodies or service providers have responsibility,'.

Ann Widdecombe: With this it will be convenient to take Government amendments Nos. 27 to 30.

John Hutton: In our earlier debates the hon. Member for North-East Hertfordshire raised his concern about who has responsibility for inspecting independent providers providing services to NHS patients. You, Miss Widdecombe, need no introduction to the subject; I remember you speaking eloquently on it in previous Committees.
 I shall not detain the Committee long on these amendments. I hope that they substantially meet some of the recent concerns expressed by Opposition Members. We are trying to preserve consistency and continuity and to ensure that the public interest is properly safeguarded. The amendments place CHI's new inspecting functions on broadly the same footing as its existing functions. The commission already has these powers of inspection in relation to its existing clinical governance reviews of independent sector 
 providers. The amendments allow it to exercise its new inspecting functions in relation to independent sector providers of NHS services in exactly the same way. In that sense they promote consistency and continuity. 
 However, there is one important difference; I hope that the Committee will bear with me while I explain it. If the commission finds that services provided by an independent provider are of an unacceptably poor quality or that there are serious failings, the amendments will not allow it to recommend that the Secretary of State take special measures in relation to those failing independent sector providers. 
 We should not lose sight of the fact that such providers are not accountable to or managed by the Secretary of State. A different set of arguments applies in relation to NHS units, on which there is clearly a direct accountability arrangement. Failure of an independent sector provider to provide services of the right quality should ultimately be a matter for local commissioners to respond to once the commission has identified a quality problem with those services. 
 The amendment provides continuity and consistency but we have decided, in the interests of common sense, to ensure that the appropriate action consequent on such a negative report from the commission is for local commissioners to respond, not the Secretary of State directly. He is not in a direct position to influence the service provided by the independent sector provider.

Oliver Heald: We have some doubts about the overall structure that will apply, as a result of the amendments, to inspections of private sector premises used for NHS purposes and pure private provision. The issue is important, given the Government's announcement—or leak—about BUPA and the hospital in Redhill. The use of our capacity to deal with the needs of patients in the private sector as well as the public sector is clearly welcome, but further use of that approach raises issues about inspection and quality.
 Last year, the Government set up the National Care Standards Commission, which starts work in April. Its job is to inspect and regulate health care in the independent and voluntary sectors, as well as social care premises. I do not understand the sense of two bodies inspecting the same premises. The NCSC will go into private premises and examine conditions. Why should it not consider what has happened to the NHS patients? Equally, the Commission for Health Improvement will no doubt inspect the premises on behalf of NHS patients, and will find things that it might feel are also relevant to the private sector. Should the inspections not be co-ordinated so that only one body visits each premises? Joint working is possible under section 9 of the Care Standards Act 2000, so may we have an assurance that that will always happen? 
 Do we need two regulatory bodies? The Government are keen on setting up committees in response to current issues, and several quality and safety bodies have been established. Historically, the 
 decision might have been sensible. About a year ago, when the Government had set their face against the use of the private sector, I remember the Secretary of State for Health saying that the NHS was thankfully a monopoly provider, and that it would long remain so under Labour. Now we hear something different. Given that circumstances have changed, is there not an opportunity to reconsider whether we need two bodies to do the same job on one group of premises? We could merely have one body for the private and public sector. 
 Today's issue of The Independent suggests that the ambition of the Secretary of State is to turn the Department into a health regulator. It states: 
 ''The Department of Health is to be turned into an 'arms length' regulator of health standards in an attempt to release hospitals from the grip of central Government control''. 
There is no sign of that in the Bill, but if it is the Government's intention that it genuinely be the regulator, that prompts two questions. First, why have a separate body—CHI—if the Government will carry out regulation at arm's length? Why not simply let the Department of Health do it? I suppose that the answer is that there is at least a flavour of independence about CHI. Secondly, why are numerous bodies needed? 
 I understand that, when the Minister and his officials gave instructions to the draftsmen, the NHS may always have been intended to be a monopoly provider. However, now that we know that the plan is different, should the thinking be reconsidered?

Evan Harris: I have looked through the amendments. I am clearly experiencing a mental block, but I should be grateful if the Minister would explain in what way they do not imply that CHI's powers to report on NHS bodies to the Secretary of State will not apply to private bodies that provide health care for which NHS bodies or service providers have responsibility. I struggle to follow how the distinction comes about.
 Will the Minister clarify the position on patients treated within the NHS estate but as private patients? Has that position changed? Is the NHS body—the hospital in which those patients are treated—responsible only if the patients are treated by NHS staff, or also if the wing is managed by the chief executive, or even if it is in the same curtilage but has a different management because there is a separate subsisting private hospital in the NHS grounds? The subject has been raised before, but it will be even more important to clarify it when we consider what the Government intend in terms of reporting the relevant bodies and providers to the Secretary of State. 
 In light of this morning's announcement about a privately managed hospital contracting for NHS work and presumably still being responsible to its shareholders, I should be grateful if the Minister would say whether that will be covered simply by virtue of the contractual relationship. The relevant body would not appear to be the NHS within the hospital, but the hospital doing its own thing for the NHS by means of a contract, service agreement or whatever the new jargon is.

Oliver Heald: Does the hon. Gentleman agree that one of the problems with a multiplicity of inspection bodies is that one of them could discover a piece of extremely worrying information but not tell another, for whatever reason? Patients could miss the full coverage of inspection that one would expect, and there would be gaps in the system. It would be good to do something to avoid that problem.

Evan Harris: I agree. The hon. Gentleman knows that my view—I think that it was also that of his party at the time of the passage of the Health Act 1999 and the Health and Social Care Act 2001—is that a unified inspectorate should consider only the quality of health care provision. The Government rejected that idea due to their aversion to lump the private and public sectors together, even for the purposes of quality assurance, which was initially understandable. As they seem to have got over their concerns on that lumping together, it seems mysterious that parallel structures are being set up. Given that the Government are not afraid to make structural reforms, even for their own sake, let alone to ensure quality, the simplest thing to do would be to unify the two bodies.

John Hutton: Obviously, I failed to make the simple case for the amendment. It would simply promote consistency and continuity. CHI already has the powers in relation to its existing ability to inspect. We are simply extending those in relation to the new range of inspections that CHI will be able to carry out.
 The hon. Member for North-East Hertfordshire raised a philosophical but fair question about the reasons for having two distinct bodies—the National Care Standards Commission and the Commission for Health Improvement. That is Parliament's decision. The hon. Gentleman disagrees with that distinction, but our arguments in favour of it are well rehearsed. He will be aware of them, as will every member of the Committee. I do not want to go into detail on that, because we can deal with the matter either in a clause stand part debate or on another occasion. 
 The amendments are simple in their intention and effect. They do not affect the issue of access to private sector premises. The hon. Gentleman was expressing concern about that, but they have no bearing whatever on the issue. The issue of access to premises is dealt with in clause 13(2). If the hon. Gentleman wants to raise any concerns about that, we can deal with the matter when we debate that clause. 
 The hon. Gentleman wants to debate the rationale behind having two inspection agencies, but those arguments are well rehearsed—we have been round that house. However, there is one issue that he was right to draw the Committee's attention to. CHI is not a registration authority. That is the fundamental difference between its role and that of the NCSC. The NCSC registers providers and gives them the authority to provide a service that meets the national minimum standards. CHI does not have that function in relation to the NHS. 
 When we were legislating to set up the NCSC we wanted, as any sensible person would, the two bodies that we felt were necessary to be able to co-operate. 
 That is what section 9 of the Care Standards Act 2000 is about. The two organisations are sensibly discussing the way forward and how their co-operation can be developed before the NCSC assumes full executive responsibility in April 2002. We would reasonably expect the majority of health care expertise to reside with CHI, so it makes sense for the two agencies to consider carefully how the work can be shared between them, in the best interests not only of the public but of the taxpayer. I have no doubt that they will do so. 
 I was thrilled and interested by the use of the word ''curtilage'' by the hon. Member for Oxford, West and Abingdon (Dr. Harris). It reminded me of the many months that I spent studying land law at university. I did not understand the term then and I have no recollection whatever of the learned lectures that I listened to on the subject. Without getting tripped up—there are many other better and more recently practising lawyers on the premises—[Hon. Members: ''No!''] I was fishing for that compliment, and I am grateful. 
 The issue that the hon. Gentleman raised is an unnecessary distraction, because the provision is not dependent on where the private hospital is located, and whether the hospital is within the curtilage of an NHS hospital is completely irrelevant. The only relevant issue is whether it provides services to NHS patients. The precise physical location of the independent sector unit—whether it is within the grounds of an NHS hospital or not—is irrelevant to the issue of CHI's competence and jurisdiction. All that matters is whether the unit provides a service for NHS patients. 
 The provision is not consequent on any other complicated set of equations, such as the precise nature of the managerial connection between the private unit and the NHS. It is certainly not determined by the physical location of the private unit. To base powers on that type of distinction would be absurd. That would make the system impenetrably obscure and would not serve anyone's interests.'

Evan Harris: I have been looking through the Health Act 1999, and I can find no reference in that Act, which the clause amends, to the sort of health care covered by the measure; services delivered to NHS patients. The Act states that duty of quality applies to providers of health care to individuals. Although I may be revisiting another debate, I would be grateful if the Minister clarified the basis for his assertion that what matters is who pays for the care rather than who provides it or has responsibility for its provision.

John Hutton: There is something in the Health Act 1999 about that; I am sorry that I cannot lay my hands on it right now. Perhaps I can resolve the hon. Gentleman's difficulty during the clause stand part debate.
 Amendment agreed to.

John Hutton: I beg to move amendment No. 125, in page 18, line 6, at end insert—
 '(za) a review under subsection (1)(b),'.

Ann Widdecombe: With this it will be convenient to take Government amendment No. 126.

John Hutton: The amendments extend the CHI's new duty to make reports to the Secretary of State where it is of the view that services are of unacceptably poor quality or there are serious failings in the way in which the responsible body is being run in terms of one of the commission's existing functions, contained in section 20(1)(b) of the Health Act 1999. The effect of the amendments will be that the commission will also have that duty in carrying out a clinical governance review. The commission will also be able to recommend to the Secretary of State that he take special measures in the event of such a report being made.
 The intention is simple. The requirement on the commission to make a special report to the Secretary of State under such circumstances should apply not only to the CHI's new range of service inspections but to its current programme of clinical governance reviews. The amendments seek to achieve that extension. I accept that it is likely that it will be some time before the commission is able to develop a comprehensive programme of service inspections. That is obvious. In the meantime, it will need to continue to focus on the completion of its planned programme of clinical governance reviews and it has an objective to complete 500 of those by 2004. It makes practical sense that, if, when carrying out a clinical governance review, the CHI reaches the view that services are of an unacceptably poor quality or that there are serious failings, it should be required to make a report to that effect to the Secretary of State.

Oliver Heald: On the face of it, the amendment seems to add a report under section 20(1)(b) of the 1999 Act to the list already contained in subsection (1D), which the clause inserts into that section 20. That list includes reports made under section 20(1)(c), those made under 20(1)(e) and inspections carried out under 20(1)(db), which clause 13(1)(a) inserts. Clearly, there is a difference in character between a (1)(c) report, which involves
''carrying out investigations into, and making reports on, the management, provision or quality of health care for which Health Authorities, Primary Care Trusts or NHS trusts have responsibility'', 
and a (1)(b) report, which is what the amendment refers to, which involves 
''conducting reviews of, and making reports on, arrangements by Primary Care Trusts or NHS trusts for the purpose of monitoring and improving the quality of health care for which they have responsibility''. 
The (1)(b) role is linked more closely to the (1)(a) role, in which advice is given. The commission's role is to give advice and promote best practice, as well as to point out the faults and mistakes committed by a health authority, primary care trust or NHS trust. Does the Minister not feel that the (1)(a) and (1)(b) functions should more properly be paired together, as they are both about improving quality through advice and help and then monitoring any improvement? Why should it be necessary, in that process, to make a report 
 and introduce special measures? I appreciate that under section 20(1)(c) of the 1999 Act, which is about the 
''management, provision or quality of health care'', 
one might want to make a report for special measures to be taken. However, I cannot understand why that would be necessary, given the more constructive approach of subsections (1)(a) and (1)(b). I should be grateful to hear the Minister's response. Bodies such as the Royal College of Nursing have said that if the provision moves us too far from the encouraging and advising role and becomes too much of a policeman role, problems may arise in the relationships that are necessary to deliver what we and the Government want, which is better health care.

Evan Harris: On the same theme, I should be grateful if the Minister could explain why (1)(d) functions are not subject to the duty to report.

John Hutton: That is the best way to ask a question and to get a Minister off balance. I hope to answer the hon. Member for Oxford, West and Abingdon in a minute, although there are no guarantees.
 The hon. Member for North-East Hertfordshire was right; various issues are raised by the different sorts of inspection. Recognising the obvious differences, the judgment call that has to be made is whether serious deficiencies identified by the commission should be drawn to the attention of the Secretary of State for him to take action. Although there are differences, the quality and standard of care needs to be considered in all inspections and reviews, and we have judged that some consistency is necessary when weakness and failure is identified. 
 Putting it in crude terms, the hon. Gentleman is right that we need a balance between the carrot and the stick, because people do not usually respond only to the stick; nor should the carrots be sticks painted orange, because that does not help either. We are trying with the amendment to achieve an effective inspection service. It could result in the commission identifying a serious failure. If it did not, the hon. Gentleman and others would rightly argue that it would be a rather fruitless exercise, but it should not be confused with a desire to beat up people in the event of poor performance being identified. The commission may identify a number of special measures that it believes the Secretary of State should take, and they may not be simple, stick-type solutions.

Oliver Heald: When I first looked at the provision, I thought that the balance had a certain logic; that one would make reports on (1)(c) situations but not those of (1)(b). The Government obviously think the same, hence the drafting. What has caused the Government's change of mind? Why is it now thought necessary to amend the clause?

John Hutton: I thought that I had explained that. As the hon. Gentleman knows, if it is to be sensible, the process of legislation should involve Ministers looking again at the provisions of legislation. I was chided earlier about a reluctance to change our minds. We have considered this provision, and given what I have
 said about consistency, about making the inspection process meaningful and about the consequences of serious failure, and given what the hon. Gentleman said about the public interest, I should have thought that he would be a little more enthusiastic about it. I am sorry that I cannot generate more enthusiasm.
 I tread quickly to the point raised by the hon. Member for Oxford, West and Abingdon about the private sector, and his inability to find any reference to it in the Health Act 1999. Section 20(1)(d) of that Act refers to 
''care for which NHS bodies or service providers have responsibility'' 
and section 20(5) describes what is meant by responsibility, and includes ''another person'' providing health care ''at his direction'', or ''on his behalf'', or 
''in accordance...with arrangements made by him''. 
That is the reference in the Health Act to providers ''other than NHS bodies''. There is continuity between that Act and the Bill. 
 The hon. Gentleman also asked a direct question about (1)(d) inspections.

Evan Harris: Clearly, (1)(d) has been replaced by (da) and (db). I was asking why the amendment covers only (da) and not (db),

John Hutton: I will have to explain that to the hon. Gentleman and to the Committee in writing.
 Amendment agreed to. 
 Amendments made: No. 126, in page 18, line 8, leave out 'equivalent function' and insert 
'function equivalent to one referred to in paragraph (za) or (a)'.
 No. 127, in page 18, line 12, leave out 'or service provider' and insert 
', service provider or other person reviewed,'.
 No. 128, in page 18, line 20, leave out 'or service provider' and insert 
', service provider or other person'.
 No. 129, in page 18, line 22, after 'provider' insert 'or other person'. 
 No. 130, in page 18, line 27, leave out 'or service provider' and insert 
', service provider or other person'.—[Mr. Hutton.]
 Question proposed, That the clause, as amended, stand part of the Bill.

Peter Atkinson: I would like to discuss two aspects of the clause that were not allowed in our debates on the amendments. First, I wish to clarify the range of the commission's power. In the 1999 Act, the commission was limited to entering NHS premises, but the Bill proposes widening the category of premises to include
''premises owned or controlled by a service provider and used for purposes connected with the services provided''. 
The phrase used in the 1999 Act and in the Bill is responsibility for ''health care''. I wonder whether the new power will allow the commission to enter premises 
 not directly involved in the provision of health care. Health care is defined in section 18(4) of the 1999 Act as 
''services for or in connection with the prevention, diagnosis or treatment of illness''. 
That could be interpreted widely. To use a slightly odd example, would the commission be able to enter the premises of a company that provided special dietary food for hospital patients? How much more widely can the commission's powers be thought of in terms of providers of health care?

Andrew Murrison: Does my hon. Friend agree that the definition offered by the 1999 Act asks more questions than it answers? It does not define health care, but illness, which is equally problematic.

Peter Atkinson: Indeed. My hon. Friend has greater knowledge of the subject than I, and he has put his finger on a further problem that the Minister might want to address.
 The second aspect that I wanted to raise was a more general point about investigations. Other members of the Committee may already know this, but I was rather surprised to learn that if a hospital calls in the Commission for Health Improvement to help it cure a problem, it is charged for its advice. For instance, the St. George's NHS health care trust in London extended its heart and lung transplant programme in October 2000, and then called the CHI to discover the reason for the substantial increase in the number of deaths of transplant patients over the previous year. It took 11 months for the report to come out. The length of time that it took to prepare caused considerable morale problems at the hospital. At the end of the day, the hospital was presented with a hefty bill, which the trust had to pay. At the time the trust argued that this was unfair, because a great deal of the work carried out in the investigation was of wider use; there was a vast cost in terms of collecting large amounts of data that was in fact relevant to the whole of the NHS in terms of transplantation. 
 What does the Minister have to say about the ability of the commission to charge, on what basis it charges and whether hospital trusts that call in the commission and are then faced with a large bill are able to dispute that bill? Who ultimately is the arbiter of the level charged by the commission?

Oliver Heald: Clause 13 provides that if the Commission for Health Improvements is of the view that a health care NHS body or service provider is of ''unacceptably poor quality'' or there are ''significant failings'' in the way it is being run, it must make a report to the Secretary of State, or, in Wales, the National Assembly for Wales, and the report may recommend ''special measures''.
 Will the Minister give us some idea of how ''unacceptably poor quality'' and ''significant failings'' are to be judged? Is this a reference to the stars system, or will the basis be one of outcomes? Will he flesh out for us what these tests are and how they are to operate? I hope that he will address my concern that there 
 should not be a barrier to innovation or new treatments. As he will know from his own experience in dealing with this area, in the mental health field there is considerable support for new therapies; talking treatments and other forms of counselling. 
 There is support for the provision of sanctuaries and holistic medicines as alternatives to more traditional therapies. There is also the cry that goes out for the latest medicines. The Minister will know that some traditionalists are less accepting of these new ideas than those who put them forward. Will the Minister assure me that quality will be based on a rigorous assessment of outcomes rather than on an approach that stifles new thinking? 
 Will the Minister explain what the special measures are? The Secretary of State obviously has the power of intervention under sections 84A and B of the National Health Service Act, which were also referred to in the Health and Social Care Act 2001. Is that what he has in mind or would other measures form part of the package described as ''special measures''? If he refers only to the power of intervention it would be helpful if that could be made clear. The Health Service Journal that he loves so well asks exactly what special measures are. The Bill states that the CHI can make recommendations where health care is ''unacceptably poor'' or where there are 
''significant failings in the way the body or service provider is being run''. 
The CHI communications director talks about a menu of special measures he is discussing with the Department of Health. The NHS Confederation is quoted as saying it is not sure what this will mean. It would be helpful if the Minister could explain what is referred to. 
 Secondly, could I ask him about the relationship between the Commission for Health Improvement and the Audit Commission? That subject has already been discussed, but in this context, if the CHI were to undertake Audit Commission work and prepare a report under the provisions of Section 21 of the 1999 Act, would it be possible to recommend special measures on the grounds that the value for money is very poor? In the light of the weekend's newspaper reports, it is clear that one great concern about the NHS is the high amount—£7 billion to £10 billion-worth—of waste. Evidence of very poor value for money should be reported immediately up the system, so that action can be taken. What special measures will be available on the ground that value for money for the taxpayer is very poor? 
 Thirdly, how widely are the powers of entry drawn? My hon. Friend the Member for Hexham (Mr. Atkinson) made the point fairly well; in fact, he made it very well.

Evan Harris: Extremely well.

Oliver Heald: Any advance on that? As my hon. Friend said, we all appreciate that it is sensible to inspect premises such as hospitals and clinics, and there is indeed a great deal of concern about diet in hospitals. However, is the Minister suggesting that powers of entry will apply to a kitchen remote from hospital
 premises, where food is prepared and then shipped to the hospital, to a blood transfusion centre situated away from the hospital or to the headquarters of a cleaning firm, so that its records can be examined? Does the power have a wide scope, or will it be limited to clinical premises?

Evan Harris: I would like to add my voice to the call for the Minister to clarify what is meant by special measures. Will they go further than the intervention orders set out in the Health and Social Care Act 2001? I am glad that the Minister has acknowledged that the fear exists that the Government are keen to decentralise blame. There is no better way to shift on to individuals the blame for the service's failure to meet expectations than to scapegoat, regardless of how much those expectations have been inflated by a Government who have failed to provide the necessary resources, whether in cash or staffing terms. There is no better way to scapegoat than to identify individuals and state that they are subject to special measures, be they franchising or discipline. That is why we have a duty to ensure that the Government set out the way in which they envisage that the special measures will be used.
 Even with an increase in alleged independence, the Commission for Health Improvement will not be allowed to criticise Government policy—even where it considers that departmental guidelines, must-dos and regulations are responsible for a failure in delivery or in quality issues—and it will be left merely with the task of identifying individuals who were unable to deliver quality despite their best efforts. 
 Having worked in the service and seen some of the things that can go on, I am as tough as anyone else on the question of quality. However, the Kennedy report took a very different approach from the one that the Government might wish to take. They might decide that those involved in what was a major quality problem acted maliciously, or that the situation could have been improved if others had been involved in management. It is true that there was a management failure and a clinical failure, but the report was at pains to point out that those involved had to cope with significant under-resourcing and geographical limitations in the provision of service. 
 The worry is that the sanctions will be used not only to deal with important quality issues—I accept that they must be dealt with—but to get the Government off the hook through their power to draw attention away from other issues that the commission perhaps cannot deal with. Certainly, hospitals in my area are very concerned—this does not help them to do their job—that the Government are standing by, ready to cast the blame on them, when they may be blameless because the job that they are trying to do is impossible with the resources that they have. There is a duty to explain what powers the Government are taking, and what measures they are thinking of introducing in the clause. 
 We will discuss later, perhaps on Thursday, prisons and the partnership between the NHS and the Prison Service. If NHS care is to be provided in prisons—some might argue that that is not before time—what 
 rights of access for the inspection of those premises will be covered by subsection (2)? It is hard to tell from the wording, without detailed cross-referencing, whether that will cover prison facilities where NHS services will be provided.

John Hutton: The hon. Members for Hexham and for Westbury (Dr. Murrison) have referred to the powers of entry. We have tried to set out in the clause where we think that those powers are needed. There is a regulation-making power alongside that, but the terms within which the powers can be exercised are set out in the Bill. Let me make it clear to the Committee that the powers will not be wider than we think absolutely necessary. I know that the hon. Member for North-East Hertfordshire is concerned about the matter and so am I. I do not want to take powers that are not absolutely necessary for the proper discharge of the commission's functions. If Opposition Members want the Commission for Health Improvement to have an inspection function over private sector providers, which has been their mantra, the Committee must address the question of the necessary consequential powers. Quite transparently, there must be a power of entry or the inspection function cannot properly be discharged.
 I know that the hon. Gentleman is a man of immense goodwill, fairness and common sense. I do not ask him to trust me—I am not naive—but I hope that, having looked at the clause, he will form the view that the powers of entry that we are taking for the commission are necessary. His hon. Friend, the hon. Member for Hexham, asked what we mean by ''premises'' for those purposes. It is defined in subsection (2)(c)(ii)(a), (b) and (c). We have tried not to hold anything back from Committee members; we have let them see everything so that they can decide whether we are taking unreasonable powers. A fair judgment would be that the powers in the Bill are reasonable. 
 The premises concerned will be clinical premises. I think that that is what the hon. Gentleman was concerned about. In the main, the premises that we have identified are those used to deliver clinical services that the NHS is commissioning from an independent provider.

Peter Atkinson: I am grateful to the Minister for explaining that. As my hon. Friend the Member for North-East Hertfordshire said, I made my point only fairly well, so the Minister may not have understood what I meant. However, to give an example, a special diet or food provider would not, from what he has said, be included in the powers that the commission has for right of entry.

John Hutton: I am not quite sure what premises the hon. Gentleman is describing.

Peter Atkinson: Kitchens, or the company that provides food in them.

John Hutton: I am reasonably sure that if a private, or even NHS, provider were using a contract supplier in a kitchen, it would be clear whether the definition in subsection (2)(c)(ii)(c) covered those premises. I am not trying to be judge and jury; I will not be making the decisions. Ultimately, it is for the commission to decide whether the premises are covered by that definition. If there is a challenge, such questions will have to be resolved in the normal way. The commission might decide that it wanted to look at premises if, for example, they had a bearing on the nutrition of patients staying in a hospital in terms of whether the food was of the right standard. However, such matters will be dealt with on a case-by-case basis; the judgment will not be mine. In the main, the definition is intended to catch those premises that the commission potentially will be able to inspect.

Oliver Heald: As usual, our concern is that subsection (2)(c)(ii)(c) is very widely drawn. Reference is made to
''any other premises used for any purpose connected with the provision of health care for which persons mentioned in paragraph (a) or (b) have responsibility'' 
and those two paragraphs are also widely drawn. The Secretary of State has the power to direct the commission; he could, if he wished, direct it to go and report on some kitchen premises that were only vaguely associated with health care.

John Hutton: No, that is not the case. The Secretary of State cannot use a direction or regulation-making power to overcome an express provision of primary legislation. On the example of the kitchen supplier given by the hon. Member for Hexham, subsection (2)(c)(ii)(c) makes it clear that the premises that he cited would have to be the under the responsibility of the person who is providing the service. If the service provider had no responsibility for the premises, he would be outwith the remit of the Bill's powers of entry and inspection.
 We are not a bunch of Nazi stormtroopers, sending an army of inspectors around the country to poke their noses into every nook and cranny of corporate and business life. The hon. Gentleman is a man of immense common sense, and I am sure that he understands that. Without trying to answer his question, because I am not fully aware of all the hypothetical circumstances surrounding it, the test that will have to be satisfied in order for his example to be defined as premises for these purposes is set out in the Bill. The service provider must have some responsibility for those premises. That is a reasonable line to draw. If he has such a responsibility, it is fair that the commission should have the power of entry. 
 The hon. Member for Hexham also referred to charging. He expressed some surprise about that matter, but it was dealt with when the commission was established, so there is nothing new about it. As far as I am aware, there have been no arguments about responsibility for charging. The CHI seeks to recover the costs incurred by the inspection, and those costs are shared with the host trust. That is the right way to fund the commission.
 I was asked what we mean by unacceptable standards. Essentially, we have to appreciate who is doing the inspection work; it is driven by clinicians and by clinical standards. Those standards will be published so that service providers, patients and the public are clear about the CHI's expectations. The fundamental question—whether services are unacceptable—will be made by the inspection team. It will be a clinical judgment based on what they have observed and what the data tells them about the service. 
 On the next point, I have to agree with the hon. Member for North-East Hertfordshire. We must not allow this proposal to become a barrier to innovation and change. The NHS is a service driven by science. Both science and technology change, sometimes daily, and it is in nobody's interests to have an inspection and regulatory mechanism that imposes a straitjacket on change across the service. There is no evidence that the CHI is discharging its responsibilities in that way. If the hon. Gentleman wanted me to put that on the record, I am happy to do so. The whole exercise must add value; it must improve patient safety, clinical outcomes and standards of care across the NHS. We will not do that by placing a ball and chain around the neck of the innovators and entrepreneurs in the health service who want to move it forward, and we have no intention of doing so. 
 I was also asked about special measures. We have not defined those in the Bill, and rightly so, because we need to allow as much flexibility as possible. Such measures could include further involvement by the commission in relation to the body or service provider. They could include special action by the NHS Modernisation Agency in terms of re-engineering or improving aspects of services being provided; they could involve the use of the Secretary of State's powers of intervention under section 84 of the National Health Service Act 1977. Specifically in relation those powers, the measures could involve the replacement of board members and involve services provided by a third party or by franchising, including management function or service provision. The CHI will make the judgment on what special measures are necessary. The measures should be interpreted not simply as a range of big sticks to bludgeon blameless people, in the sense used by the hon. Member for Oxford, West and Abingdon, but as sensible measures to help to improve services for patients.

Oliver Heald: Is the Minister suggesting that the CHI would set out in its report what special measures were needed, rather than simply saying that there is a case for special measures and leaving it to the Minister to decide what they are, so that we would all know what is being proposed in each case?

John Hutton: I think that that would be the case, but the decision on what special measures should be taken will be a judgment for the Secretary of State. We shall not do that in a dark and smoke-filled room because the matter should be open to public inspection. We are trying to improve the public's national health service. The NHS does not belong to us or to the hon.
 Gentleman, but to the whole country and we have a responsibility to the public to conduct the debate as openly as possible.
 The final point that was raised is the familiar hobby-horse of the hon. Member for Oxford, West and Abingdon; blame. The hon. Gentleman is obsessed with blame. That is a disappointing reaction and repetition of a flawed analysis based on a mistaken assessment of what the provisions are about. It is motivated essentially by a purely partisan assessment of the Government's actions. On each of those three counts, he is wrong. This is not about a blame culture, but about the necessary actions that the Government must be able to take to move from a position in which services are constantly criticised to putting in place the measures to address those complaints. 
 We have a responsibility, and the hon. Gentleman and I have a completely different view of that. Whatever his judgment about the direction of policy in the national health service--he disagrees fundamentally with it, as is his right--it is fully the responsibility of Ministers in any Government to suggest solutions to the problems. We can argue and argue about the nature of the problems, but we must go beyond the historic dilemma of poor results and performance in the NHS. That has always been addressed by Ministers in previous Governments, Labour and Conservative. 
 We know where the poor performance is and we can identify it. The hon. Gentleman can identify it in his own constituency. We need to put in place the measures to address such poor performance. Part of the solution is investment and we are providing that. Part of it is reform and we are making reforms; the provision is part of those reforms. We are constructing a mechanism to identify failures quickly; not subjectively, but informed by clinical assessment by the best people available to do that work. We will then construct the solutions. That is not blame; it is the Government discharging their responsibility to the public to put right poor performance. To characterise that as blame is to traduce and trivialise the arguments. It is a schoolboy debating point. The hon. Gentleman needs to go beyond that and engage with the serious issue of how we put right service deficiencies. 
 Part of the solution involves money, but money is not the whole solution. The Liberal Democrats think that everything can be solved with a shed load of cash, but that is simply not so. We must provide the cash, investment and reform and we must take measures that are sometimes difficult for people in the service. I accept that, but we must not flinch from taking the tough decisions required to put right poorly performing NHS providers. If we do not do that, we sell the pass and negate our responsibility to the House and our constituents, which is to address problems with public service delivery.

Simon Burns: Perhaps I can help the Minister, who is being a little unfair to the hon. Member for Oxford, West and Abingdon. Is the Minister aware of the comments that one of his harshest critics, the hon. Member for Winchester (Mr. Oaten), made at the Liberal Democrat party
 conference? He said that he thought that we needed to debate public services. He said that although the audience would not like it—I am sure that the hon. Member for Oxford, West and Abingdon does not like it—when we look at the health service we need to look at ''issues of insurance'', ''issues of charging'' and ''issues of hypothecation''.

John Hutton: There we are.

Simon Burns: Is that not helpful?

John Hutton: It is a tempting morsel. I was being a little unfair to the hon. Member for Oxford, West and Abingdon. It always makes me feel good when I am unfair to him; not for any personal reason, but because I find his party's position utterly pathetic. Its claim that the problems of the NHS can be solved by investment alone is not borne out by events; it is not a tenable position.

Evan Harris: Will the Minister give way?

John Hutton: I shall give way to the hon. Gentleman in a moment. I shall be fair to him because he wants to entertain us with his views.
 We must invest, and we are doing so at record levels, but reform is also essential. The reforms that we are implementing through the Commission for Health Improvement are fundamental to challenging poor performance. The sensible way to reform is not by being judgmental, but by using opinions that are informed by the best clinical expertise.

Evan Harris: It is difficult to respond to all the Minister's remarks in an intervention, and I may seek to catch your eye after he has spoken, Miss Widdecombe.
 I shall not be sidetracked out of order by the Minister's invitation to comment on how the NHS is funded. It is possible to believe that the NHS requires more resources, more staff, better staff morale, better retention, functional rather than structural change and an assurance of good quality; I do not demur at any of that. As we discussed earlier, the danger is that the Commission for Health Improvement is allowed to focus only on quality issues associated with end delivery rather than on the directions, resources and policies to which everyone is forced to work. Bad outcomes are glorified; people may think that sacking or replacing a manager is the solution to the problem, when the Minister would accept—I do not blame only him—that other things need to happen. That is what I mean when I say that the focus of blame is on the end result—the manager who is sacked—rather than on other issues that the commission is prevented from tackling by the terms of the Bill.

John Hutton: The commission will need to identify the source of the problem in any particular trust or hospital. In some cases, there may be a need for a change in management, which, if that were the reason for the problem, would be inescapable.
 A failure to address poor performance would depress morale in the NHS more than anything else. One can go to any hospital in the country and talk to nurses, doctors, therapists, cooks and cleaners who will say whether their team, department, trust or hospital is performing well. What turns many of them off is the realisation that, although problems have been identified over a long period, nothing has happened. Providing a poor service is the easiest option; none of this is easy because this is not the easy option. 
 The hon. Member for Oxford, West and Abingdon always berates us for taking the easy way out. He describes the clause as a way in which to pass blame elsewhere. These are not easy solutions, as anyone who has read the CHI reports and studied their comments on quality of care will immediately understand. We are holding up a mirror to the NHS, and it will show us things with which we shall not be happy. However, it will also show us some fantastic things, and we must give credit where it is due. Such credit is down to the hard work of nurses and doctors, and it is essential that we make that clear. We shall discover uncomfortable things when we hold a mirror up to the NHS. Our responsibility is not to shuffle our feet and say that the situation is too difficult and that if we act, we shall upset and offend people. That is the way to sell the pass on the future of the NHS. The public have high expectations on which they expect us to deliver. 
 I have said a great deal more than I intended, but the clause is important. I would say that, but it is my genuine belief that this is an essential plank in equipping the CHI with the tools that it needs to do its job properly and broaden its remit and function. If we are to use the independent sector more frequently to provide NHS care, which we will, we must ensure that the NHS gets the highest quality care when it uses those providers. That is the clause's function.

Evan Harris: I want to make three points. First, I invite the Minister to respond, which I am sure that he will in a moment, to the statement about access to the Prison Service. Secondly, will he clarify which powers he has in mind other than those set out in the intervention orders in sections 84A and 84B of the 1977 Act? The explanatory notes to the clause state:
 ''Such measures could include the use by the Secretary of State of his powers of intervention under sections 84A and 84B''. 
That implies that there may be other undisclosed powers that have not yet been established. Will the Minister cast some light on what those powers might be? 
 I do not want to have an endless debate, and I shall not rise to the bait given by the Conservative party's hard-working Liberal Democrat unit, which hunts out quotes from a democratic party conference where we debated future policy. 
 The third point, which concerns whether the Commission for Health Improvement holds up a mirror to the NHS, is key. We have already established that the commission is unable to comment on resources, which is one of many issues for which I do 
 not hold this Government, as opposed to the Government in the previous Parliament, wholly responsible. 
 The commission will not be allowed to question the terms of reference under which the NHS is working. If, for example, patients are badly treated in terms of quality of care, in that they are not given urgent operations because the Government have decided that the priority is a patient who is stable and not clinically urgent, but who is coming up to a maximum waiting time limit—be that 18 months, 15 months, 12 months or six months—and patients die while waiting for urgent operations as a result, the Commission for Health Improvement will not be allowed to comment, criticise or analyse the terms of reference, directions and criteria that commissioners and providers have been given by the Government, because the Government have said that it cannot do so. All that is left for it to do is to say that management should have stopped this happening. Management must not do the Government's bidding, and doctors should certainly not do their bidding, when it is a choice—these choices are sometimes difficult, but this one is obvious—between clinical need and political need. 
 That dilemma in which managers and clinicians find themselves is one reason why there is such poor morale in the health service. The Government are not the first to have tried this because there are Conservative Members who recognise this problem. We do not have a balanced approach to quality in respect of the powers that the Secretary of State will take from the clause. 
 I understood the Minister's point, and he made his case—I hope he takes this the right way—eloquently and strongly in his rebuttal of my main point. However, there is nothing here but a straightforward disagreement. He thinks that it is acceptable for the Government to be partly responsible, not necessarily advertently, for bad things happening in terms of quality, and for the Commission for Health Improvement only to recommend that action should be taken against managers who may feel that they were doing the Government's bidding. We will be unable to make further progress with this discussion. I hope, however, that the Minister will accept that I am not saying that the issue is all about resources, staffing or morale, but that a complex mixture of factors are involved in the delivery of poor care or a lack of access to care. The way in which the commission is set up with its veneer of independence will see blame being allocated publicly to individuals through the exercise of these powers, and not to the processes. 
 A reading of the Kennedy report reveals that the system, not individuals, is responsible for many quality problems. We miss the point when action is taken only against individuals. If one considers the media coverage of the Bristol royal infirmary's problems, the disciplinary action taken, which was similar to that recommended in the clause, against the doctors and management concerned—the General Medical Council was not necessarily wrong—made it appear before the Kennedy report was published that the only issue was surgeons killing babies and managers letting them do so. The Kennedy report, 
 which had a much wider remit than I fear the CHI would ever be allowed to have, clearly said that there were system failures, failures from chasing waiting-list initiatives, and a long-standing failure of resources. That is the point that I have been trying to get across. 
 I feel that we may not agree any further, but I do not want to repeat debates that we had this morning. It is not simply a matter of calling for more resources. To characterise the points that I am making—I feel that I am making them on behalf of people working in the health service, such as clinicians and managers—is to bastardise a very important argument, and a point that needs to be put.

John Hutton: I would like to respond briefly to the point that the hon. Gentleman asked me fairly, which I failed to deal with in my rush of enthusiasm to be unkind to him.
 The CHI will have access to NHS services wherever they are provided, whether in prisons or elsewhere. We can come back to this issue when we reach clause 21, as my hon. Friend the Parliamentary Under-Secretary of State will be dealing with that part of the Bill. The very simple answer to the hon. Gentleman's question is that it will. We have a much broader disagreement, but I think that the hon. Gentleman should be wary about casting himself in the role of spokesperson for the NHS. There are always two sides to this argument. 
 The complaint that I hear loudly and clearly when I visit hospitals and speak to people working in the NHS is that they are sick and tired of no action being taken in the event of poor performance. They want us to take that action, and they want it to be done fairly. It is not about blame, and it is not about identifying individuals. I think that it is very important that we have a set of arrangements in place that will allow us to address those persistent and well-documented failures in performance, and that we do so sensibly. 
 The hon. Gentleman is being over-precious about his wider argument and the way in which he used the Kennedy report to support his argument. The Kennedy report is very clear about what the role of the Secretary of State should be. The appropriate function of the Secretary of State is to set standards, to provide resources, and to set the overall framework within which priorities should be set and delivered. It is also the job of the hon. Gentleman—along with all hon. Members on both sides of the House—to engage the Secretary of State so that he is held accountable for the decisions he makes. It is not the responsibility of the CHI to surpass the role of members of this House in holding the Secretary of State to account. 
 Question put and agreed to. 
 Clause 13, as amended, ordered to stand part of the Bill.

Clause 14 - Commission for health improvement: constitution

Question proposed, That clause 14 stand a part of the Bill.

Oliver Heald: In clause 14(3), the CHI is given the power to discharge any of its functions either via a committee, a sub-committee or an employee. However, an addition is made, referring to ''any other person''. We would like to know who this other person is likely to be. Is the Minister suggesting that another public sector body might become involved; for example, as we discussed earlier, the Audit Commission? Or is he referring—because of the way it is worded—to private sector providers? If so, does he intend that the CHI might want to involve in its work opinion research, private investigation agencies or some other body in the private sector? Can the Minister tell us what type of persons he has in mind?

Peter Atkinson: Lawyers.

Oliver Heald: Personally, I see no harm in involving knowledgeable individuals concerned with the law in any arrangements. I should be grateful to the Minister if he declared his interest as a lawyer. Is the measure simply to make work for lawyers, as he put it earlier?
 Under clause 14(3)(c), the CHI's committee and sub-committee members will be known as the Office for Information on Health Care Performance. Why is it necessary to give legislative cover to that office? Will it have a separate budget? What is its legal status? Will it be a separate body within the commission? Will it have the ability to contract? What is the relationship between it and the Office for National Statistics? Will it publish statistics and, if so, what safeguards will there be in terms of the independence and methodology of such statistics?

Evan Harris: I should like briefly to discuss the annual report. In earlier debates, the Minister mentioned the wider issues that I felt might be missed because of the relatively narrow scope, in terms of examinable tiers, of the commission's inquiries. The Minister prayed in aid the annual report, which might allow the commission's commentary on the state of the NHS to touch on issues that go wider than the microscopic level of inspection of individual hospitals. However, it is not clear that the proposed statute will grant such a power. Clause 14(4)(b)(1A) merely specifies that
''the Commission must also make a report to the Secretary of State and the National Assembly for Wales on what it has found in relation to NHS bodies and service providers in the course of exercising its functions during the year.'' 
Perhaps the Minister intends that the report should think out of the box—I hate that term when it is used by management-types—that he has drawn for the commission by insisting that individual inquiries must not take into account the terms of reference to which trusts must work. However, it might not be clear to the commission that it can do more than summarise its findings. If the Minister takes this opportunity to reassure me—or otherwise—on that question, we will know more clearly where we stand.

Richard Taylor: May I, too, ask for some clarification? I am very confused by paragraphs 7 and 4 of schedule 2 to the Health Act 1999. Paragraph 7 states that
''the Director for Health Improvement is to be appointed by the Commission, but his appointment requires the consent of the Secretary of State.'' 
Paragraph 6, which is being deleted, implies that the commission can appoint lesser employees with a free hand, but under the terms of paragraph 4 it is clear that the Secretary of State will retain control of appointing the chair and members of the commission. What is the explanation for those potential inconsistencies, and why will the independent NHS Appointments Commission not be involved in such appointments?

John Hutton: May I, for the benefit of the Committee, summarise the changes that clause 14 will make? I shall then try to address the concerns that were raised.
 Clause 14 is at the heart of what we mean by decentralisation. The Commission for Health Improvement will be released from the control of the Secretary of State, as it were, and in that regard there are four or five important changes. Clause 14(2)(a) will remove the requirement for the Secretary of State's consent in appointing the commission's chief executive. I should tell the hon. Member for Wyre Forest (Dr. Taylor) that there is no confusion about that; the question of who to appoint as chief executive will a matter for the commission itself. Clause 14(2)(b) will remove the Secretary of State's power to direct the appointment of employees and their terms and conditions of employment, and it is clear that that relinquishment applies to the chief executive as well. 
 Clause 14 (3)(a) and (b) will extend the commission's ability to delegate to any other person, and will allow the CHI to pay remuneration or allowances. That relates to the point made by the hon. Member for North-East Hertfordshire, who intervened to ask to whom the phrase ''any other person'' referred. 
 Subsection (3), and (3)(c) in particular, refers to such matters as the Office for Information on Health Care Performance. In such areas, there are many bodies outside the commission—such as the medical royal colleges, universities and other academic research bodies—that have developed considerable expertise in analysing data. It would be broadly inefficient for CHI to duplicate that detailed work, so it is important to give it the flexibility to involve outside organisations in discharging its responsibilities. 
 The final responsibility must be with the Commission for Health Improvement, but we do not want to reinvent the wheel. It makes sense to allow further delegation of responsibilities so that we can make full use of the expertise of other bodies. That must, and will, be done under the auspices of the commission, but the facilitating provision will allow the commission to use outside expertise as it develops its work. I think that that is a positive, consensual idea. The fullest possible range of expertise that exists in the country must be made available to the CHI. That is what we mean by ''any other person''. 
 Clause 14(3)(c) relates to and names the new 
 '' 'Office for Information on Health Care Performance'.''
The hon. Member for North-East Hertfordshire raised questions about its legal effects. The office will not have a separate legal status from the CHI; it is part of the commission and will not contract separately from it. The hon. Gentleman asked me why it was included in the Bill. There are various reasons. There is an analogous precedent in how we set up the National Care Standards Commission, with the children's rights director separately identified in the Care Standards Act 2000. 
 It is important that the CHI develop its role and function in this area. To emphasise the importance that we attach to it, we have identified the function and office in the Bill. That will attach the greatest significance to it, just as the creation of the children's rights director in the 2000 Act attached great significance to that post. The provision does not set up a separate or free-standing entity, but it signals the importance that the Government and, I hope, the House attach to improving this aspect of the CHI's function. 
 Clause 14(4)(a) makes it clear that the commission will continue to publish a standard annual report on how it has carried out its functions. Clause 14(4)(b) requires it to make a further annual report to the Secretary of State and the National Assembly for Wales on the quality of services to NHS patients. The clause requires the Secretary of State to lay both annual reports before Parliament, and the National Assembly to publish the report on the quality of services. 
 It will be for the commission to decide what issues it wants to raise in the report. The Secretary of State will not write the report, but the Bill clearly obliges him to lay it before Parliament. That is one reason why the clause is important. This will be the first time that this place will have access to such evidence. There has never been an annual ''state of the NHS'' report produced in such a way. I am sure that it will show a mixture of things; some good and some poor performance, and many people working hard to improve matters. 
 It is important for the quality of our future debates on the NHS that that provision is in the Bill. It will aid and abet our work in Parliament and is a positive sign of the Government's commitment to improving the quality of debate on the future of the NHS. It will also serve an important secondary function; ensuring that the public have greater confidence in the information reported to them. The commission is being positioned further away from the Department of Health so that we can avoid the usual unpleasant allegations that Ministers are torturing the data until it confesses and tells them what they want to hear about the NHS. That is not what we are interested in. There is a strong case for having a warts-and-all argument about the NHS because that is the best way to engage with the issue that matters to the people of this country; the future of our most cherished of all public services.

Richard Taylor: The Minister has not answered my question on the appointment of the chairman and members for the Commission for Health Improvement.

John Hutton: No, I have not; I forgot. We do not propose any changes to that system. They are Nolan appointments, and I hope that the hon. Gentleman is satisfied with that reassurance. Appointments will be carried out in the right way.

Evan Harris: Will the Minister address my point about the ambit of the annual report? I asked whether it would be restricted to a summary of findings or whether it would, as he hinted—perhaps I misheard earlier—be more wide-ranging and broader in its thrust.

John Hutton: It will be more wide-ranging and broader in its thrust. I thought that I had made that clear.

Richard Taylor: May I register concern about the Minister's reply about the appointments being Nolanised, as it were? I am not sure whether I speak for the whole country but, in our area, appointments made by the Nolan commission have not always been as free from political influence as they were supposed to have been. I should have much preferred the new appointments to be made by the independent NHS Appointments Commission. The Minister has not said why that will not be so.
 Question put and agreed to. 
 Clause 14 ordered to stand part of the Bill.

Clause 15 - Establishments of patients' forums

Evan Harris: I beg to move amendment No. 163, in page 20, line 3, leave out subsections (1) and (2) and insert—
 ''(1) The Community Health Councils established for districts in England under section 20 of the 1977 Act are reformed and are renamed Councils for the Involvement of Patients and Public (''Councils'') and the Community Health Councils Regulations 1996 are amended accordingly.
 (2) The Secretary of State shall, following consultation with the Association of Community Health Councils for England and Wales, Community Health Councils, patients' and carers' organisations and the wider community, make regulations in relation to Councils in England providing for—
 (a) the inclusion in Councils' annual reports of details of the arrangements maintained in that year for obtaining the views of patients, carers and the wider community in their localities;
 (b) the commissioning of, or delivery by, Councils of services under section 19A of the 1977 Act (independent advocacy services) within their areas;
 (c) the preparation of reports on the operation of the independent advocacy service to be compiled by Councils and provided to the Secretary of State, the Commission for Patient and Public Involvement in Health, the relevant overview and scrutiny committees, Strategic Health Authorities, NHS trusts, and other appropriate organisations;
 (d)(i) promotion by Councils of the involvement of members of the public in its area in consultations or, processes leading (or potentially leading) to decisions by those mentioned in section 19(3), or the formulation of policies by them, which would or might affect (whether directly or not) the health of those members of the public;
 (ii) co-operation with the Commission for Patient and Public Involvement in Health in carrying out this function;
 (e) the provision of advice, reports and recommendations by Councils to strategic health authorities, Primary Care Trusts, NHS trusts, and overview and scrutiny committees;
 (f) the furnishing and publication by NHS trusts, Primary Care Trusts, Strategic Health Authorities and overview and scrutiny committees of comments on the reports, recommendations and representations of Councils referred to in paragraph (e) above and paragraph (h) below;
 (g) the discharge of any function of a council by a committee of the Council or a joint committee appointed with another Council;
 (h) representation by Councils of the views of members of the public in its area about matters affecting their health to persons and bodies which exercise functions in a Council's area (including in particular the overview and scrutiny committees and the joint overview and scrutiny committees mentioned in sections 7, 8 and 10 of the Health and Social Care Act 2001);
 (i) co-operation with The Commission for Patient and Public Involvement in Health in its duties.''

Ann Widdecombe: With this it will be convenient to take the following amendments: No. 171, in page 20, line 21, leave out ''(2)(c)'' and insert ''(2)(e)''.
 No. 172, in page 20, line 22, leave out ''Patients' Forum'' and insert ''Council''. 
 No. 173, in page 20, line 24, leave out ''Patients' Forums'' and insert Councils''. 
 No. 174, in page 20, line 27, leave out subsection (5)'. 
 No. 175, in page 20, leave out line 39. 
 No. 176, in page 20, leave out lines 44 and 45. 
 No. 177, in clause 16, page 21, line 15, leave out ''Patients' Forums'' and insert ''Councils''. 
 No. 178, in clause 16, page 21, line 20, leave out ''Patients' Forum'' and insert ''Council''. 
 No. 179, in clause 16, page 21, line 22, leave out ''Forum's'' and insert ''Council's''. 
 No. 164, in clause 19, page 23, line 20, leave out subsection (1) and insert— 
 ''(1) the Association of Community Health Councils for England and Wales established under paragraph 5 of Schedule 7 to the 1977 Act is reformed as a body corporate and is renamed the Commission for Patient and Public Involvement in Health; the NHS (Association of Community Health Councils) Regulations 1977 and the Community Health Council Regulations 1996 are amended accordingly.''
 No. 165, in clause 19, page 23, line 23, after ''following'', insert ''additional''. 
 No. 182, in clause 19, page 23, line 32, leave out ''Patients' Forums'' and insert ''Councils''. 
 No. 167, in clause 19, page 23, leave out lines 36 and 37. 
 No. 183, in clause 19, page 23, line 36, leave out ''Patients' Forums'' and insert ''Councils''. 
 No. 184, in clause 19, page 23, line 41, leave out ''Patients' Forums'' and insert ''Councils''. 
 No. 169, in clause 19, page 23, line 45, leave out paragraph (g) and insert— 
 ''(g) co-ordinate and support the activities of Patients' Councils in respect of their activities provided for at sections 15(2)(h)''.
 No. 185, in clause 19 page 24, line 35, leave out ''Patients' Forum'' and insert ''Council''. 
 No. 154, in clause 20, page 25, line 21, leave out subsection (3).

Evan Harris: It is almost with a feeling of trepidation that I begin the debate on these important clauses. I note that my amendments have been signed by Conservative Members and I welcome that. Before the Minister tries to judge what I am about to say, patient and public involvement is not something that divides, or should need to divide, along party political lines. We should all be in the business of finding the best solution.
 Resources do not play a huge part in the clauses. Many types of formula have been hit on to find the right approach, and the amendment constitutes one of them. I am happy for it to be described as a varied, amended or reformed status quo; that is what the Government intend for the NHS. The Minister has just said that it is not the intention to tear up or abolish the NHS and start again. On that basis, it is reasonable and appropriate that the Government consider amending the system before cancelling it out and imposing a new one. 
 A few things will be said at the beginning of the debate that will have been heard before, but bear restating. Those who support the amendments, which address the existing community health council structure, and those that address clause 19, which address the reform of the Association of Community Health Councils of England and Wales—here, we are talking about England—do not necessarily feel that every community health council is as good as another. In earlier debates, we would not have argued that every provider, or commissioner, was as good as another, even if they had all been given the same resources. However, that does not mean that we should abolish the lot. We should not abolish every provider or commissioner simply on the basis of varied performance; we should seek to ensure that they have the right powers, the right monitoring and the right support, both from the centre and from their own staff, to do the best possible job, at least to minimum standards. 
 Throughout this debate, which has now spanned two Parliaments, the Government have never set out clearly enough why the current system cannot be reformed and has to be abolished. That point has been made at length by Conservative Members, Liberal Democrat Members—including my hon. Friend the Member for North Devon (Nick Harvey)—and the former and current Chairmen of the Select Committee on Health.

Simon Burns: Does the hon. Gentleman agree that the Government have never coherently, or even satisfactorily, explained the need to abolish CHCs and replace them with another structure?

Evan Harris: Quite so. That is a useful and clear summary of my preamble.
 One argument that the Government could deploy is that the performance of community health councils is patchy, as is that of the Association of Community Health Councils in its various functions. However, they have never commissioned a report to analyse the failings of individual CHCs and to find out whether they are failing as a result of their mere existence, 
 rather than as a result of their under-resourcing, having the wrong personnel, their inappropriateness to their geographical function or the fact that they have been too easily bamboozled by the local health care players that they are there to monitor. It is incumbent on the Government to present such a case before going for wholesale abolition instead of considered reform. 
 I greet the Under-Secretary and apologise for not having done so earlier. I know that she is prepared to listen and to consider the issues, and she probably does not bring much with her in the way of set views; she is relatively new to her job, although she seems to have been here for a long time because she has made a big impact. However, I suspect that some of her more senior colleagues have an absolutist position and will not consider anything short of what they originally envisaged. If that is so, it is regrettable, and it should be made explicit. I fear that it will not be made explicit, but it will be made regrettable; if not here, in another place. 
 The second argument that the Government could use to justify the abolition of CHCs is that they do not have the right powers for the ''new'' NHS; the NHS that the Government have created and are in the process of structurally recreating through almost every piece of legislation. Indeed, that argument was more than hinted at by the Secretary of State on Second Reading, when he complained: 
 ''The CHCs had no role in primary care; patients forums''— 
the Government's preferred model— 
''will have that role. The CHCs were refused the right to inspect GPs' premises; patients forums will have that right. The CHCs were partly appointed by the Secretary of State for Health; patients forums will all be appointed independently of both the Secretary of State and indeed the NHS. The CHCs had no formal rights of representation within NHS organisations; patients forums will elect, as of right, one of their members to sit on every trust board.''—[Official Report, 20 November 2001; Vol. 375, c. 203.] 
The obvious response to that was given by the hon. Member for Wakefield (Mr. Hinchliffe), the Chairman of the Select Committee. He said: 
 ''I accept that CHCs do not deal with primary care issues, but they could do, as the Secretary of State is aware. It would be easy for them to deal with those sectors that they have not been allowed to address. We need to modernise the CHC structure.''—[Official Report, 20 November 2001; Vol. 375, c. 214.] 
I was surprised to hear him use the word ''modernise'', as I think that he has similar views to mine about its overuse in describing pointless reforms. I suppose that he was playing the game, as we all do sometimes. 
 In respect of all the powers that the Secretary of State described, the law could be changed to give them to CHCs. I hope that that is what the amendments would do. The Government have made an important point in saying that CHCs do not have the right powers to fit the shape of the NHS. The straightforward and simple solution to that is to make the necessary reforms to ensure that CHCs have those powers. 
 Apart from CHCs not having the right powers, I cannot think of any other good reason for the Government to abolish them, other than the patchy performance that is a function of their existence, rather 
 than being something that can be ameliorated. The Government have not taken such an approach with other parts of the NHS. 
 I will briefly go through the amendments to remind myself of their details and to help the Committee. Although in your wisdom, Miss Widdecombe, you have selected the amendments for discussion under clause 15, many of them apply to other clauses because they are consequential. With your permission, we will have to discuss some of the issues in the other clauses when dealing with those amendments. They must also be read with amendments that would have deleted whole clauses. They were not selectable because such matters should be dealt with under a clause stand part vote and not through discussion of an amendment. I hope that Committee members recognise that some of their amendments would be in this group were they selectable. 
 Amendment No. 163 would delete subsections (1) and (2) of clause 15 and substitute new subsections that would, in effect, rename community health councils. I think that that is worth doing, and I will explain why. I will also set out what would be their powers, and the powers of the Secretary of State to make regulations about them. 
 On the name, perhaps the Government feel that anything redolent of the old NHS needs to have its name changed and that ''community health council'' does not impart the idea of the need for patient involvement that they want. Those who tabled the amendment therefore thought it reasonable to rename community health councils as ''councils for the involvement of patients and public'', which can be abbreviated to CIPAP. Any other combination of those words does not lend itself to that abbreviation, but for the ease of the Committee, we refer to them as ''councils'' in the other amendments. The Minister and Committee members will notice that many of the proposals refer to patients forums as ''councils'', meaning these bodies. 
 The new subsection (2) that amendment No. 163 proposes sets out the councils' functions. Amendment No. 171 would change ''(2)(c)'' in clause 15, page 20, line 21 to ''(2)(e)'' because of necessary renumbering. Because of the pressure of time, it is not now appropriate to go through the functions in detail, but I will draw out a couple of them, to help the Committee. 
 The proposed new subsection (2)(b) discusses 
''the commissioning of, or delivery by, Councils of services under section 19A of the 1977 Act (independent advocacy services)''. 
There is an argument that the reformed community health councils—that is, these councils for the involvement of patients and public—should continue to attempt to deliver such independent advocacy. It was, however, often noted in the consultation that Ministers do not feel that such bodies should have a monopoly on the delivery of independent advocacy services.
 Now is not the time to argue about that. I have some sympathy with the view that diversity can be helpful and that, as we commission all sorts of things in the national health service, it is reasonable to commission independent advocacy services. 
 That is why the clause is drafted in terms of the commissioning or delivery of independent advocacy services by councils. We could argue that separation is needed because the councils are later asked to make a report on the quality of the independent advocacy services. It may be appropriate to ensure separation within the new councils or separate delivery from the commission. 
 The Under-Secretary will see that many proposals for the powers of the councils are familiar to her. They are the sorts of powers that she wants her patients forums to have; many community health councils still have them. 
 Some of the amendments would replace patients forums with the new councils. Clause 19 contains an important provision to give internal symmetry to the proposals by renaming the Association of Community Health Councils for England and Wales the Commission for Patient and Public Involvement in Health, which is a creature of the Government. It recognises that the existing structures can be reformed in the way favoured by the Government for the new NHS. Clearly, some functions will be common to the renamed association and the Government's creature; a separate non-amended body, the Commission for Patient and Public Involvement. 
 One of the reasons why we want to remove clause 19(2)(g) from the Bill is that the Government envisage the national body as having the ability to get to the nitty gritty of local decision making through overview and scrutiny committees. That function is inappropriate for a national body and therein lies the problem with the Government's proposals. The patients forums simply will not have the facility to engage properly with the overview and scrutiny committees and to influence the committees' statutory powers of calling in. The Government suggest in clause 19(2)(g) that a national body can have that power, but it is surely too centralised and unwieldy. It seems reasonable to ensure that built into this arrangement is the ability of the Government's patients forums to allow councils to liaise at local level. Whatever decision is taken on this group of amendments, clause 19(2)(g) will require further thought. 
 Time is pressing and there will not be time for me to go into the detail of all the amendments in this group, but I hope that I have given the flavour of our overall approach. I accept responsibility for and absolve other hon. Members who tabled the amendments if they are not complete. I fear that the proposal to abolish clause 20 is not included, but we shall have a chance to deal with that later and it may be inappropriate to try to abolish it now. Some matters are not covered, but we can only do what we can do. Help has been provided by the Association of Community Health Councils for England and Wales, which is busy at the moment with 
 its statutory functions. I hope that the Minister will not simply rely on the fact that there may be drafting errors in the amendment and that he will address the substantive proposal. 
 In summary, I believe--I hope that other Committee members agree--that our approach is rational. The Government must demonstrate why it is inappropriate and why they must abolish community health councils without first trying to reform them.

Simon Burns: I am genuinely fascinated to know what line the Under-Secretary will take in her reply, because from 1993 to 1997 she was chair of the Salford community health council. No doubt she did a good job and came fully to appreciate what a valuable contribution that community health council made to the lives of the people of Salford by acting as an independent voice in health care provision and helping individuals in the community with their problems. It also played an important role in the local area in helping to advise, formulate and fulfil the provision of health care for Salford. At last, we have a Minister who knows something about the subject that she is debating, but she will have to behave like a juggler to repudiate the views that she held so deeply during that period.
 I am not a cynical man, so I will not say that the hon. Lady loved and supported the proactive role of community health councils in 1993 to 1997, because the Government in those days were Conservative, not Labour. She saw the role of the community health council as emphasising the problems facing the health service at that time. If that had that a knock-on effect politically, it was all well and good for the Labour party. 
 During the prolonged debates that we had on the abolition of community health councils and the imposition of patients forums in the past six to nine months, I have noticed that this Government, who brook no opposition and hate the idea of any criticism, see community health councils as too successful, independent and determined to do their job properly in representing the interests of local people with regard to the provision of health care. I suspect that Ministers in the Department of Health petulantly decided that they would rid themselves of this ''troublesome priest.'' They came to the conclusion that it was not in their interest and did not fit in with the spin that they like to put on their policies for there to be an independent, free-thinking organisation doing to a tee the statutory duties that were imposed on community health councils at their inception. 
 To bolster the need for the amendments, one has only to consider the record of community health councils over the 27 years since their inception in 1974. You will know, Miss Widdecombe, that those councils were established as patient advocates in the NHS. By any criterion that one chooses, their success in being good, formidable patient advocates is beyond dispute. 
 They have been at the forefront of ensuring that the patients' voices are heard and their complaints listened to. 
 Most recently, community health councils played a pivotal role in ensuring that Rodney Ledward was exposed and that the relatives of the victims of Harold Shipman were supported during a difficult time. I suspect that if hon. Members were honest, they would admit that such people have done a good job. The hon. Member for Crawley (Laura Moffatt) is a former state-registered nurse, so she will have first-hand experience from the other side of the excellence of the work of community health councils. If all members of the Committee examined their souls, they would know from their experience as constituency MPs—not as Ministers or poodles to the Government Whips Office, but as individual Members of Parliament representing their constituents—how good a job the community health councils do, by and large. 
 Of course there is a case against the community health councils, as I am sure that they would be the first to admit. In some areas, they could be improved. Certain community health councils and some of their members may not be as efficient as others. There are grounds for improvements, but that does not necessarily mean that there are grounds for the abolition of an independent voice and its replacement by a poodle. The patients forums as envisaged by the Government are nothing more than a lapdog. They are an attempt to silence opposition to what is going on in the health service, and to deprive our constituents of an independent and powerful advocacy service on their behalf. 
 To put that in perspective, I would like to mention what the community health councils have done to justify their retention, albeit in a reformed format. On average, they assist around 30,000 people with complaints. A recent poll conducted by Health Which? found that 84 per cent. of those who had contacted their community health council at some point found the advice given very or fairly useful, which suggests an extremely high satisfaction rate. 
 A recent report, ''Hidden Volunteers'', conducted by the Community Service Volunteers estimated that community health council members contributed through their dedicated work about £7.9 million worth of free labour for the national health service. No one in the Room would underestimate their work—those who would must be extremely brave. People have devoted their time and effort to ensuring that the institutions that Parliament set up in 1974—according to research, the Labour party was in favour of it at the time—have more than fulfilled their potential, and continue to do so even as we discuss their future yet again tonight. 
 The trouble is that community health councils are a thorn in the Government's side. To be effective, they have to be a thorn in the side of every Government, regardless of their political persuasion. That is their role as an independent advocacy service. They are there when trusts and health authorities propose to close wards to save money. They have the real power 
 to get such decisions called in to Ministers if they do not agree that they are in the best interests of local communities. 
 I will give the Under-Secretary an example that shows how the people of mid-Essex must be more than grateful in the end—it is sad that I have to say in the end—for the work of their community health council. The management of the Mid Essex Community and Mental health trust was fairly rotten until 18 months ago. In the end, it was replaced, and Ministers would be the first to accept that that was the right decision, certainly based on waiting list figures. The then management decided to close two wards in an attempt to save a little under £1 million to combat its financial problems. The way in which the proposals were implemented suggested that that money would not be saved because of the ensuing bed blocking, but the two wards would have been closed and all those acute care beds would have been lost. 
 In the end, the community health council stepped in and formally objected, which meant that the matter had to go to Ministers. It turned out that the community health council was absolutely right. The wrong decision had been taken—it would not achieve any savings or improve the provision of health care in any shape or form—and the community health council put a brake on the process. The trust abandoned the proposals; a decision that has been more than justified over the past 18 months. Without a community health council with those powers, those closures would have gone ahead and the situation for the provision of health care in mid-Essex would have been even worse than the trend suggested. 
 That shows the importance of community health councils and that is why it is important that the Government should think again and be prepared not to proceed with an idea that they cannot justify. During the debates on the Health and Social Care Act 2001 earlier this year, another place, thank heavens, through a combination of its Members' actions and the time scale of the general election, managed to stop this proposal from going ahead. Sadly, Ministers, almost as if they are feeling insulted that Parliament has stopped a proposal, however cock-eyed and difficult to justify, seem to believe it should be punished after the election by bringing back what is to all intents and purposes the same proposal. 
 No doubt the Under-Secretary will try to produce a fig leaf, not only for her own change of heart on the effectiveness of community health councils but for the proposals in this Bill, which are similar to those in the previous ones, although in some ways they are even worse. 
 The amendments would enable the Secretary of State to revise and extend existing regulations governing the operation of community health councils so that they might be retained and reformed in England. Of course, Miss Widdecombe, you will have noticed, as will any other perspicacious Member of this Committee, that community health councils will not be abolished in the Principality of Wales. It is a pity that the Under-Secretary of State for Wales, who has attended many of our Committee meetings, is not here. 
 It would be interesting to hear his views as to why Wales is allowed to continue with the structure of community health councils, but England is not. [Interruption.] I thought that I heard ''devolution'' from an hon. Member on the Labour Benches; I have no doubt that that is the reason. Why is it that a devolved Assembly in Wales, which-unless my mathematics and my memory are wrong; the First Minister is a Labour politician-is run by the Labour party, has had the common sense to keep the community health councils in the Principality?

Evan Harris: I do not know whether I am assisting the hon. Gentleman or the Labour party by pointing out that the Administration in Wales is a partnership between the Labour party and the Liberal Democrats. Who knows exactly who has taken which position, but it is likely that one of the conditions of that partnership government was that there was true democracy at local level in the community in the health service and that is why CHCs were saved.

Simon Burns: If I understood that intervention correctly, the hon. Gentleman was claiming that because of conditions laid down by the Liberal Democrats community health councils are being retained in Wales. I am afraid that I have no way of verifying that fact. I hesitate to take it at face value, not simply because it is a Liberal Democrat claim, although that plays a role in my hesitation, but because the hon. Gentleman did not categorically say that that was the case. He said that he thought that that might be the case. Will he clarify the matter?

Evan Harris: There are many reasons why Wales has a different system. First, the Assembly has a system of proportional representation that allows partnership government. Secondly, there is partnership government, which means that matters are not decided in the politburo negotiations of a single party. Thirdly, at least one party in Wales—possibly two—is concerned about the exercise of local democracy, democracy in the health service and adequate patient and public oversight, and seeks to retain the CHCs on that basis.

Simon Burns: The hon. Gentleman's figures are wrong. There are not only two parties in Wales with those concerns, because the Conservative party in Wales also supports the continuation of community health councils. I cannot believe that Rhodri Morgan would retain community health councils in Wales if he did not believe that they should be retained. Unusually, I would give the Labour party in Wales the credit for that sensible policy. As I said earlier, I only wish that the Under-Secretary for Wales were here tonight, because he would be able not only to elaborate on the mechanics of the matter but to explain to the Committee why it is important for Wales to retain these invaluable bodies and for the English not to do so.
 Wales has got it right and the Government have got it totally wrong in England, because they cannot realistically explain why they are hell-bent on taking this action. They are making a grave error. If the proposals are approved in another place, the Government will deprive all our constituents of a service that is proven, tried and tested. It works, is independent and has the interests of local communities and their health care at heart and conducts advocacy on patients' behalf in a highly effective way. 
 I would say to the Under-Secretary, particularly as she is a new Minister, that she should think again, because there are ways, as the amendments suggest, in which community health councils could be reformed to meet any criticisms that the Government may have. The failings apparent to the Government, but not to many other people in the country, can be remedied. The Under-Secretary is making a grave blunder at the beginning of her ministerial career if she puts behind her her first-hand experiences as the chair of a community health council and, for narrow, party political dogma and to silence opposition and criticism, decides to go ahead with a pernicious and petty proposal.

Richard Taylor: I shall be brief, because time is short, but I must make two points in support of amendment No. 163. As an illustration, I would like the Under-Secretary to put herself in the shoes of somebody in my county. We have three major conurbations with three community health councils, so patients have to go only to one CHC for any of the services that are currently and, I hope, will continue to be, within its remit. Under the new arrangements, there will be five patients forums, and a given patient in one of the conurbations might have to consult three separate organisations. That is my first point—what a tremendous inconvenience. CHCs have all services under one roof.
 The second point is about the constitution of CHCs, which include representatives from the voluntary sector who in my experience not only represent their own voluntary sphere but act as very good spokespersons for the whole community. They also include a number of elected councillors, and that introduces a democratic element. There is also a relatively small number of appointees. It does not appear that forums will be constituted in the same way.

Andrew Murrison: I must say that the Bill is not exciting a great deal of enthusiasm among my constituents, but if I were to pick out an item from it that has raised a collective eyebrow it would be the proposal to abolish community health councils. CHCs have been going for about 27 years. It takes a long time for people to get used to institutions, but they have finally got used to CHCs. Broadly speaking, people know what they are and the geographic area that they cover, and they are comfortable with them. CHCs are like a pair of old carpet slippers; people have become used to them. Now, for no good reason, the Government propose abolishing them; they want to throw out the comfortable carpet slippers and replace them with
 something unknown. In all likelihood, it will be another generation before people are fully used to the change and comfortable with the replacement. Doing that with good reason is fine, but we have yet to be provided with a good reason for disposing of CHCs.
 The Association of Community Health Councils of England and Wales was upset. It does not understand why the Government want to abolish it, particularly as its feedback suggests that it is doing a good job on behalf of patients, carers and the general public. It said: 
 ''The proposed alternatives to CHCs, as set out in the Bill, fall far short of meeting the widespread concerns about the independence of the new bodies and their lack of integration. If the Secretary of State pushes ahead with the Bill in its current form patients will lose a respected, effective, independent health Watchdog and in its place they will get a system that is more fragmented, more confusing to the public and less independent.'' 
That is quite polite. A good analogy would be of poodles and watchdogs. We are losing a watchdog, and it will be replaced by poodles—lots of them. There will be fragmented poodles, poodles for primary care and poodles for secondary care. 
 Where is the joined-up Government in that? Surely we should have a seamless join between primary and secondary care. People do not necessarily distinguish between the two. They know when they are unwell that they need access to health care. It would be far more helpful to have fewer such watchdogs—watchdogs that will take people through the whole multi-tiered layers of the NHS, from primary to secondary and tertiary care, but hopefully not beyond that—but it should be seamless. People do not want to be bothered with multiple tiers and multiple layers. They want a one-stop shop. That is what they have now; and that is what they are about to lose. 
 Except for patient forums, patients lack a collective voice. The community health councils are recognised by the public as somewhere to go if they have concerns about the health service. They will be abolished. As a general observation, it seems that the Government have started from the standpoint of wanting to abolish CHCs—it seems to be a constant theme—but they have not told us why. They do not explain adequately how the functions of CHCs will be carried out under the new system. They merely present us with alternative institutions. 
 The notion that the Government started with the idea of abolishing CHCs without knowing exactly why and without knowing how the replacements for CHCs would carry out the functions currently undertaken by CHCs is my principal concern about the Bill.

Hazel Blears: I am delighted to have the opportunity, under your chairmanship, Miss Widdecombe, to deal with the amendments. I hope that I can enlighten members of the Committee about the reason for the Government's proposal and that I can even convince one or two of them that the new system will be more independent, integrated, accessible and accountable and much stronger than the previous system. It will give patients a much better and more vigorous voice within the national health service—and beyond it.
 I shall now mention the amendments tabled by the hon. Member for Oxford, West and Abingdon. I shall be generous and not go through the detail of them because they would create a jumble of functions between patients forums and the commission. Many names would be changed. I did not think that the hon. Gentleman favoured style over substance, but his amendments skim the surface of the proposals rather than deal with the in-depth nature of the changes that the Government want to make.

Simon Burns: If the Under-Secretary considers that our amendments and those tabled by the hon. Member for Oxford, West and Abingdon are poorly drafted but concedes the case that they make, surely she can allow her own fine parliamentary draftsmen to knock them into shape.

Hazel Blears: The amendments are beyond being able to be knocked into shape. They fail to appreciate the nature and depth of the Government's proposal. I shall deal with their substantive nature, however, rather than the way in which they are drafted.

Evan Harris: The hon. Lady said that the amendments would merely change names. I hope that she will accept that they would, in fact, reform the existing system, including the change of name. We should not just change names when we say that we are making reforms, but carry out the reform. I am upset that the hon. Lady has accused me of doing what the Government have tended to do.

Hazel Blears: I shall not lengthen what is a fairly superficial debate, but the amendments would change names.

Simon Burns: Superficial?

Hazel Blears: The hon. Members for Oxford, West and Abingdon and for West Chelmsford—[Interruption.]

Ann Widdecombe: Order on the Opposition Benches, please.

Hazel Blears: Both hon. Gentlemen have asked us to explain why we want to replace community health councils with patients forums working inside each trust. That is the key to the matter. We want bodies that are within the structures of the national health service that can really act as levers for change. We want them to drive up quality and have sufficient influence and clout within the system to make a difference for patients, and we want them to be balanced by equally strong bodies on the outside, which can effectively overview and scrutinise the system.
 It is a difficult balance to strike but, in the past, the community health councils had virtually all of their powers on the outside. They often reacted after events had occurred. They were often not able to influence the shaping, the configuration and the options that were being developed about the health service. They felt that, no matter what their powers were, those powers were exercised in response to events. They were reactive organisations. I say that with some feeling, having been a chair of a community health council for several years and having often been faced with a set of 
 events in which I had no alternative but to threaten legal action because I and my association had no right to be on the inside and to be party to such decision-making processes. A fundamental part of the Government's proposal is to ensure that not only patients, but members of the public have a voice in shaping the health service from the inside. Clause 15 is the key to achieving that, because it recommends patients forums in each trust. The forums will be able to work from the inside. They will have a member on the trust board. They will know what is important to patients and will be able to do something about it.

Evan Harris: I am grateful to the Under-Secretary for allowing me to interrupt her flow. She argued that community health councils were currently too responsive and reactive. Why not make them less responsive and reactive by—to use the hon. Lady's words—bringing them on board for each primary care trust? Why cannot she give councils for the involvement of patients and the public at local level a place on the trust board, as she proposes for her own creation?

Hazel Blears: I hope that, when the hon. Gentleman can appreciate the breadth and sweep of the provisions under clauses 15 to 20, he will see emerge a coherent system that will provide an influence on the inside that is balanced by a rigorous scrutiny position on the outside, too. Taken as a whole, that system will fulfil the need of patients and citizens for a stronger voice. I hope that I shall convince the hon. Gentleman during our debate that we shall not have a mish-mash or a jumble of provisions, which, with respect, his amendments would put in place, but a coherent system. At trust-based level, the patient advocacy and liaison services system and the patients forums will be on the spot. On the outside, the scrutiny will be done by the commission, the local workers of the commission, the independent complaints and advocacy service and the overview and scrutiny committees of local authorities. That provides a real balance to ensure rigour, strength, accountability and integration in the system.

Evan Harris: The Under-Secretary will know that it is her proposals, at their various stages, which have been called a mish-mash. I did not attack her proposals. Before she defends her proposals, she must say why the existing structures cannot be reformed to provide exactly what she has described. Nothing in the amendments says that the PALS system should not exist, or that the overview and scrutiny committees should not exist. Before she talks about her coherent system, she has a duty to explain why the existing one cannot be made coherent through reform and legislative change.

Hazel Blears: And I certainly will do that. If one takes out the PALS system, which is the on-the-spot advice, patients forums, which provide the monitoring and inspecting, and the right to refer contested decisions to Ministers, which is the overview and scrutiny part of
 the community health council's functions, one already has a denuded organisation. There comes a point at which, after one separates out the functions and makes them stronger and more integrated, what is left is an empty shell of an organisation. Therefore, one must have a new system that properly reflects a multi-layered organisation such as the NHS, and one must ensure that the voice of the patient is heard at every single access point to the health service. Taken as a whole, that is a coherent system.
 I am afraid that the hon. Gentleman is suggesting that, as well as all the other things, we have some kind of additional body. That would really be a mish-mash system, and very difficult to understand.

Simon Burns: Why does the Under-Secretary think that the Labour Chairman of the Select Committee on Health is not convinced by her arguments?

Hazel Blears: When my hon. Friend the Member for Wakefield (Mr. Hinchliffe) was promoting patients councils during debates last year, he was promoting a different animal from that which is referred to as a council in the amendments. He was seeking to provide a body within the system that would draw together all the patients forums and ensure that all those views were brought together regularly, to engender within the health community a sense of the issues being raised at local level. That would ensure that patients forums were not isolated in each trust and unable to get their view across. Under the Government's proposals, the local parts of the Commission for Patient and Public Involvement in Health will provide exactly the function of the patients councils advocated by my hon. Friend the Member for Wakefield. They will be patients councils plus, because they will have a number of extra statutory powers. Therefore, we are building on the proposals of my hon. Friend the Member for Wakefield, rather than simply putting them in place.

Simon Burns: Then why is the hon. Member for Wakefield changing his view in his opposition to what the Under-Secretary is seeking to do?

Hazel Blears: I think that my hon. Friend the Member for Wakefield will be interested to look at the discussions in this Committee. The conclusions that he reaches are a matter for him. Some of the proposals genuinely build on the ideas that he advanced, but his ideas are very different from those in the amendments tabled today, which refer to turning patients forums into patients councils, which was not within his contemplation at all. He was talking about co-ordination, drawing together, learning the lessons and joining up the system, not replacing patients forums with patients councils, which serves to confuse the matter even more.
 I shall now explain why the new system is necessary, and why we need patients' forums. The NHS is more complex and multi-layered, and different functions are needed in different parts of the system. Most people involved in community health councils would recognise that there was inconsistency across the piece. Some brilliant community health councils were doing 
 fantastic work, but it would not necessarily be done the same way in Bristol, Bath, North Yorkshire and Cornwall. Performance was extremely patchy. 
 The hon. Member for West Chelmsford mentioned the fact that my community health council in Salford did some excellent work. I can also confirm that, for years, it has been trying to pilot new ways of working, which we are proposing to use to involve citizens and find groups who are never involved in public consultation. We want to involve the socially excluded and marginalised: homeless people, asylum seekers, travellers, young people, those who cannot turn up to a meeting on the second Tuesday of the month at the public library, but whose views are equally valid in shaping the health service. The most progressive community health councils carried out that sort of public involvement work and welcomed those ideas, so they have drawn in the views of the wider community. 
 Over the past six months, I have devoted much time to our listening exercise—talking to CHCs, councils for voluntary service, local authority groups and a range of voluntary groups in the NHS. We have had nine regional listening events and 1,000 people—

Simon Burns: The Under-Secretary outlines the extensive consultation. How many members of CHCs told her that she was right to abolish them?

Hazel Blears: There were 1,000 people at the consultation meetings, and we have received 1,000 letters, one of the biggest ever responses. Many CHCs welcomed the proposals.
 As well as many patient organisations that have welcomed the proposals—

Simon Burns: Come on.

Ann Widdecombe: Order.

Hazel Blears: I received a personal letter written on behalf of Wirral community health council. The writer said that at the council's meeting on 15 November, it examined the Department's latest proposals—we had changed our proposals because we do listen and it was a proper exercise in consultation. The writer of the letter said that members of the CHC agreed that the new proposals offered a much more cohesive approach. They applauded the emphasis on co-ordination of the new structures at a local level by the Commission for Patient and Public Involvement in Health. They commended the inclusive nature of the consultation. They said that they themselves were piloting new ways of working, engaging local people in health decision making. They said that in November, they would be presenting to local MPs an evaluation of their pilot NHS comments hotline and that whilst the announcement in the NHS plan of the intended abolition meant an uncertain year for them, they had worked hard to embrace the spirit of reform heralded by the plan and had no doubt that the new proposals would ensure that that position was enhanced and strengthened. I am delighted that, after a year of
 consultation, Wirral community health council welcomed the proposals with such open arms; it is not alone.

Evan Harris: Does the hon. Lady accept that she is a Minister for England, not just the Wirral? If she is going to increase support one body at a time, it will take several years before she can cover a county. How can she argue that the amendments are dealing with an empty shell when all the reformed CHCs' functions, including PCT representation on boards, are set out in amendment No. 163? Are those functions important?

Hazel Blears: The functions are extremely important, which is why they belong to the patients forums inside each trust. Other bodies must carry out functions in a coherent system of patient and public involvement. We need a new system to create powers to follow patients wherever they go in the system. Patients forums can work together. In primary care trusts, a patients forum will allow us to study the premises of GPs, dentists and pharmacists. Where joint arrangements with local government exist, patients forums will also have the power to follow people in local authorities. In private sector arrangements, a condition of the contract will be that patients forums are allowed to monitor, inspect and ensure that the quality of services is up to the mark.
 CHCs, no matter how good they are, would acknowledge that they are not fully representative of their communities. My constituency CHC is not because it is a static membership organisation that meets on the second Tuesday of the month. It tends to be self-selecting in the sort of people who can, or want to, take part. It is mainly politicians who enjoy going to meetings on the first Monday, the second Tuesday, the third Wednesday and the fourth Thursday of the month. Asking people in a voluntary sector setting to give that type of commitment is sometimes extremely difficult. We need to be more creative and more imaginative about the way that we seek to involve patients and the public in a range of public services, but particularly in the health service. 
 What I find very disappointing about the amendments that have been tabled by the Opposition today is the fact that they are designed to perpetuate the status quo. From the Conservatives I am not surprised but I am surprised that we see the Liberal Democrats in alliance with the forces of reaction. I am surprised that they do not want to be forward looking or progressive or to raise their sights and consider whether there might be better ways to involve the public and patients in our health service. Do they simply want to say that the status quo is good enough? [Hon. Members: Hear, hear.] Certainly that is not my view. I believe that we have a challenge and a duty to improve the way in which we involve the public and citizens in our public services.

Evan Harris: I am finding this Committee stage rather a metaphysical experience because we go from broad generalisation about the need to involve people and the forces of reaction to the citing of the fact that there is something in the existing legislation surrounding CHCs—or something in the water that they drink—
 that restricts them to second Mondays and third Tuesdays. I find this whole debate surreal. I want the Minister to address the argument, which I tried to make constructively in my opening remarks, that there is no reason why all the powers and new models, systems and, presumably, meetings in the ether rather than at a specific time cannot be used by reforming, not reacting to the existing system.

Hazel Blears: I have tried to explain to the hon. Gentleman that his proposals to—as he says it—reform simply tinker with the system at the margins. They do not reflect the new shape of the NHS or that, as I have said we shall have PALS on the spot in the trust. We shall have patients forums inside the trust, levering up standards and quality. We have already transferred the legal duty to refer contested reconfigurations to the local authority over the scrutiny committee; that is one function that has already gone. We shall have the Commission for Patient and Public Involvement in Health, specifically charged with being the grit in the system to bring some rigour and ensure that we involve a wide range of people—whose voices have traditionally not been heard—in shaping the way that our health service develops. It will be a statutory body, whose job it will be to go out and create community capacity, to find the people, to populate all of these mechanisms and to ensure that those people can have a real say and make a real difference to the way that the health service works.
 It is not right simply to reform the status quo. What is needed is a completely fresh look at the system. The best CHCs were doing some of that good work. We want to set up a new system that reflects the way in which we are devolving power to the PCTs—a system that ensures that patients and the public have a say at every single level within the system, that they are properly empowered to make a difference. There is nothing worse than asking local volunteers—I readily acknowledge that many members of CHCs have given 10, 15 or 20 years of fantastic voluntary work—to go on to bodies without the necessary back-up, training, education, support and guidance to enable them to feel that they can make a real difference in the decisions in which they are asked to participate. That is the type of system that we want to set up. We want to create a band of really active citizens who are able to shape the health service that they pay for as taxpayers—and long may it remain so—and therefore deserve to have a real say in shaping.

Andrew Murrison: We have heard about these armies of volunteers who will spring up and populate patients forums, PALs and everything else. Those of us who have experience of the voluntary sector and specifically of CHCs know that it is extremely difficult to get people to volunteer for them. I would be fascinated to know where the hon. Lady will get this army of volunteers to populate her new bodies.

Evan Harris: The Wirral.

Hazel Blears: No, they will not, they will come from their own communities and they will come because they will feel that they can make a difference. The one thing that motivates people to become involved in public sector activity or service is the feeling that the two or three hours a week that they have to spare is being put to good use. They want to feel that they are not sitting in meetings dealing with correspondence, apologies and matters arising, but are making a difference to the health service.
 I shall give the Committee an example. Recently I visited Somerset and saw independent health panels at work. People are asked to serve on them completely at random, so it is a varied group of individuals, and they sit on the panel for three years. They learn the ropes in the first year, engage in the issues in the second and are mentors for the new first-year people in the third. It is independently facilitated and all the decisions in the health community are referred to the health panel for consideration. At the end of the sitting, the panel has a matrix to show which proposals were changed as a result of its consideration. 
 During the period that I was told about, the panels had made a difference in 72 per cent. of issues. The members of those panels told me that that was why they wanted to be involved. They did not expect all the suggestions that they made to be adopted, but they realised that their two hours a week could make a difference to shaping the health service. That is not about sitting in static meetings, but about being engaged because members consider that the national health service is important, care enough about it and have the experience. 
 Half the people on patients forums will be recent or past patients and the other half will be voluntary sector organisation representatives. If they can examine a particular task or service—maternity, urology or coronary heart disease services, for example—that will engage people. We must also tell people that we value them and ensure that they are compensated for time off work. We must ensure that they can find the next step in their voluntary activity, and that we give them training, education and support to bring them through the system. We must tell them that their voluntary work is valuable and that we want to draw on their expertise, knowledge, talents and potential. We must also go out and find people, so that we do not depend on the normal people who can come forward. We must ask whether we have anyone to represent the black or travelling communities. Is anyone speaking for the homeless or young people? 
 In my constituency, we recently consulted people with Alzheimer's. People would say that we could not consult those with Alzheimer's, but we did. It is hard work, but if we are determined we can go out and do it. That is how we get volunteers to take part: value them, bring them forward and make extra efforts to bring them in. That is why we must be creative. Simply moving amendments that ask for the status quo is not the way forward for our health service. It does not value people's contribution and put them on the inside of the system in the patients forum, where they can make a difference, and tell the trust board that 
 something is wrong and that they want something done about it. They can call people to account and drive up the quality and performance in the health service. That is why patients forums are crucial to the measures that the Government want to put in place, and that is why I ask all hon. Members to resist the amendment.

Evan Harris: As a Committee member asking the Government not to do something, I feel like the sole patient or public voice on one of the new boards. Will the Government suddenly be so cowed by such a volunteer that they say, ''Of course, we are wrong. The fact that you are here as a representative of a patients forum and not a community health council means that our historic approach to ignoring, if we have been ignoring, patient involvement has been entirely wrong''? I suspect that the majority of board members who are supposed to jump to the voice of the lone volunteer will behave like the Government in Committee today. They will not really address the concerns that have been raised—any more than the Under-Secretary has today—but merely restate mantra-like the fact that things must change.
 I invited the hon. Lady to explain why community health council-type organisations had to be abolished rather than reformed. That was my challenge. I put it to her that the fact that they were variable did not mean that, with all the powers of legislative change, the Government could not impose minimum standards and issue guidance to ensure that that variability did not exist. The Secretary of State is rather good at making regulations and, if practice makes perfect, he should be getting better, although I am not too sure about that. The Under-Secretary has not addressed my challenge. 
 I cited the hon. Member for Wakefield because he asked, as I did, why the focus of community health councils cannot not be created around the new communities if the Government believe that those councils do not have the relevant powers or shape, or why they cannot change their names, if the Minister thinks it appropriate. Why can those councils not have the necessary functions once other organisations have been set up? Why can there not be reform and evolution, which the Government use as a defence, in the Bill? 
 The Government do not say that they will abolish all hospitals when some hospitals under-perform. They do not abolish a position when some people are not doing a job especially well or do not have the relevant powers. They defended their action on that basis when they did not abolish general practitioners, but gave them the powers to commission. That has also not been addressed. When hon. Members of either House come to consider the issue, it is important to stress that the Under-Secretary has not dealt with it. 
 The Under-Secretary says that the system is coherent, and cites in her defence what appear to be her own deeply held views, which one CHC seems to endorse. That is little more than the power to aver that something is so. She claims that when PALS are set up, 
 when scrutiny committees exist, when there are patients forums in every hospital or members of those forums on the trust board, all that would be left would be an empty shell once the other functions had been given to the reformed CHCs. I believe that those CHCs could be the bodies with a member on each trust board. 
 I invited the Under-Secretary to consider the list of powers that the amendments would still leave with those reformed CHCs, which she describes as empty shells with nothing valuable to do. I also invited her to consider the inclusion in councils' annual reports of details of the arrangements maintained in that year that pertained to the views of patients, carers and the wider community. [Interruption.] The hon. Lady is arguing from a sedentary position—a point that she made, in fairness—that patients forums will have that role. She has not addressed my question about the Government's need to create a new structure when the existing structure could use the experience and enthusiasm of the people already involved—[Interruption.]—because they have been through a lot recently—

Ann Widdecombe: Order. I am sorry to interrupt the hon. Gentleman, but several conversations are taking place and it makes life difficult for the Hansard writers.

Evan Harris: The Under-Secretary must explain why the existing structure, with all its powers and the enthusiasm of those of whom she spoke so warmly when she talked about the notional new volunteers, cannot be channelled towards the kind of functions that she wishes to see. The amendments include the duty to ensure that the views of patients, carers and the wider communities are obtained. That would not make the reformed CHCs empty shells.
 The commissioning and delivery of independent advocacy services by CHCs in their areas is an important function, and not one that would be found in an empty shell. The preparation of reports on the operation of the independent advisory service that would be provided to the Secretary of State, the Commission for Patient and Public Involvement in Health, the overview and scrutiny committee, strategic health authorities and trusts is an important role and not that of an empty shell. 
 It is also the function of community health councils, as reformed, to promote the involvement of members of the public in their area in consultations or processes leading, or potentially leading, to decisions by those mentioned in clause 19(4) 
''or the formulation of policies by them, which would or might affect (whether directly or not) the health of those members of the public'' 
and to co-operate with the Commission for Patient and Public Involvement in Health to carry out that function. That is in the Bill, so the Under-Secretary cannot simply dismiss the amendments for not addressing points on which she waxed extremely lyrical. Those features are in the proposals that I am recommending. They set out important duties, before 
 a decision is made. The roles that the Under-Secretary said were so important are proactive. I believe that she sincerely believes in the importance of duties such as 
''the discharge of any function of a council by a committee of the Council or a joint committee appointed with another council'' 
 ''representations by Councils of the views of members of the public in its area about matters affecting their health to persons and bodies which exercise functions in a Council's area''. 
The amendments show, if one accepts drafting errors, that such duties can be achieved through the current system. 
 Much has been said about the refusal of people in the other place and the outside world to accept reform, and about how unreasonable they were when the previous Bill had its passage. I suspend judgment on that because, at the time, I was not doing my current job or involved in negotiations, although I studied the debate. However, the surreal quality of our debate and the Under-Secretary's refusal to explain why the existing system could not be amended to provide for the nirvana of volunteering that she described makes me believe that, if anything, people in the other place were too willing to meet the Government halfway. Perhaps they will still be willing to do so. The Under-Secretary will have to do a better job of persuading them and me why the existing functions are not important. 
 The Under-Secretary mentioned the importance of making a real difference and described how people in the community could do so. She veered off to dismiss all the work that members of community health councils have done to date. Even the people whom she does not believe to have done their job properly have worked hard. Then she veered toward the other danger of being patronising to people who fulfil that role, which she will be keen not to do. I urge her to exercise caution. If the Under-Secretary lifts her ambition and understands that people do not require their roles to be abolished or to be kicked in the face to achieve her aims, we have a real opportunity. I am prepared to accept PALS and Liberal Democrats have accepted overview and scrutiny committees and the need for patient involvement at board level in primary care trusts and in other areas. Negotiations are the order of the day, but the starting point must be to amend the existing system. That is the rational way in which to make law and structures and to approach reform. Unless the hon. Lady shows that she is prepared to examine the matter wider, I intend to press the amendments to a vote.

Hazel Blears: I shall deal with the hon. Gentleman's points briefly. I did not say that the functions that he proposed for his councils were unimportant. All the functions are vital and will be carried out by either patients forums or the commission. The hon. Gentleman's amendments would jumble up and blur the boundaries between the functions of the patients forums and the commission. Each function that he outlined is extremely important and is totally covered
 by either the patients forums or the commission. I do not say that the functions need not be carried out or supported.
 I made an explicit point that the proposals build on the best of work done by community health councils and, especially, their members. I went out of my way to recognise the years of excellent voluntary commitment that people have given to community health councils. I know many such people personally, and it is wrong for the hon. Gentleman to say that I patronised them or dismissed their contributions. I wish to find a transition through which staff and members may find new roles within the new organisations. We have gone out of our way to do so and to ensure that people will be helped if they require extra support and training to take a new and enhanced role in the new system. The Society of Community Health Council Staff welcomed the proposals. I attended its annual conference three weeks ago, and 150 members were present. Following my presentation I did not know how what reception to expect, knowing how controversial the proposals were last year, but I was received extremely generously. 
 I received a testimonial, which I shall not read out, from the chairman of the society, Tony Tester, to say that the society welcomes the proposals from the point of view of community health council staff. Every effort has been made to ensure that we draw in the best ideas of the CHCs and of members. We will set up a transition advisory board to ensure that members in the system see a key role for themselves in future and can take on new responsibilities. 
 I want to respond to the points made by the hon. Members for Wyre Forest and for Westbury. To the hon. Member for Wyre Forest I say that it will be important to provide proper signposting to the new parts of the system that are designed to involve patients and the public; the patient advocacy and liaison services system will be on the spot in the trusts, more visible and accessible to everyone than community health councils. 
 We shall arrange for NHS Direct to provide a signposting facility so that anyone who telephones with a query needing independent complaints and advocacy services will be pointed in the right direction. If they need PALS, or want the commission to help them in taking part in a public consultation they will be able to get in touch with them. We want to make the system as accessible as possible. 
 We want to ensure that members will be appointed at local level by the commission and draw on people to take part in the patients forums who would not automatically reply to an advertisement in The Guardian, for example, and go through a formal process. We want rigorous criteria and selection procedures, but we also want to make them flexible enough to draw in groups that have not been well represented in the past. 
 In response to the hon. Member for Westbury, I am not sure that most community health councils would like to be described as a pair of old carpet slippers. Many of their members are forward-looking, progressive, imaginative and creative people who put a great deal of work and energy into drawing people into 
 public consultation and involvement. People take time to get used to institutions but I hope that in the new system they will find a range of mechanisms in a rigorous system that enables them to get properly involved and to influence the shape of health services, rather than a comfortable pair of old carpet slippers.

Andrew Murrison: The Under-Secretary is being meddlesome. She knows full well that my comments about carpet slippers were made in the best possible sense and were to do with familiarity, which is important for the public in such matters.
 Question put, That the amendment be made:—
The Committee divided: Ayes 5, Noes 8.

Question accordingly negatived. 
 Motion made, and Question put, That the clause stand part of the Bill:—
The Committee divided: Ayes 8, Noes 5.

Question accordingly agreed to. 
 Clause 15 ordered to stand part of the Bill. 
 Further consideration adjourned.—[Mr. Fitzpatrick.] 
 Adjourned accordingly at half-past Seven o'clock till Thursday 6 December at half-past Nine o'clock.